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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/operativesurgeryOOmcgr 


Operative  Sttrg-ery 


For  Students  and  Practitioners 


JOHE"  J.  McGRATH,  M.D. 

Professor  op  Surgical  Anatomy  and  Operative   Surgery  at  the  New  York  Post-Graduate  Medical 

School,  Surgeon  to  the  Harlem,  Post-Graduate,  and 

Columbus  Hospitals,  New  York. 


Second  edition,  Thoroughly  revised 


With  265   Illustrations,  including   many   Full=page    Plates   in 
Colors   and    Half-tone 


Philadelphia 

F.  A.  DAVIS  COMPANY,  PUBLISHERS 

1906 


A1I7 


COPYRIGHT.  1905, 

BY 

F.  A.  DAVIS  COMPANY. 
[Registered  at  Stationers'  Hall,  London,  Eng.J 


Philadelphia.  Pa..  U.  S.  A. 

The  Medical  Bulletin  Printing-house. 

1914-16  Cherry  Street. 


PREFACE  TO  SECOND  EDITION. 


Operative   Surgery  appears  in  its  second  edition  after 

having  been  carefully  and  thoroughly  revised.    Many  instructive 

illustrations  and  much  new  and  interesting  descriptive  matter 

have  been  added.    In  the  section  upon  the  abdomen  the  subjects 

of  gastroenterostomy  and  the  surgical  treatment  of  diseases  of 

the  stomach  and  intestines  have  been  treated  in  minute  detail. 

The  operative  surgery  of  the  pancreas,  spleen,  etc.,  has  also  been 

described  at  length.    The  recent  advances  in  the  surgery  of  the 

prostate  gland  have  received  due  consideration  in  the  revision  of 

the  section  upon  the  urinary  organs.     It  is  believed  that  these 

new  features  will  very  greatly  enhance  the  usefulness  of  the 

book. 

J.  J.  McGrath. 
October  1,  1905. 


(iii) 


PREFACE. 

i 

In  this  volume  an  endeavor  has  been  made  to  combine, 
in  a  practical  manner,  the  subjects  of  surgical  anatomy  and 
operative  surgery,  because  a  knowledge  of  the  one  is  essential 
to  the  proper  study  of  the  other. 

Diagrammatic  drawings  have  been  used  largely  for  the 
purpose  of  illustration,  because  these,  in  my  judgment,  are 
the  most  satisfactory  for  teaching. 

An  effort  has  been  made  to  exclude  all  those  anatomical 
considerations  that  are  purely  technical  and  not  of  practical 
value  in  the  performance  of  surgical  operations. 

The  arrangement  of  the  subject  has  been  made  in  accord- 
ance with  the  plan  followed  in  my  courses  in  operative  surgery 
at  the  Post-graduate  Medical  School. 

John  J.  McGrath. 


CONTENTS. 


PAET  I. 
General  Considerations 1-19 

Anaesthesia:  General  anaesthesia,  1;  incomplete  general  anaesthesia,  2; 
local  anaesthesia,  2;  Schleich  infiltration  method,  3;  analgesia  by  sub- 
arachnoid injection  of  cocain,  4. — Division  of  Tissues:  Division  of  soft 
parts,  5;  division  of  bone,  6. — Hemorrhage:  Means  to  arrest  hemorrhage, 
7;  natural  arrest  of  hemorrhage,  7;  artificial  arrest  of  hemorrhage,  7. — 
Suture  of  the  Tissues:  Suture  of  the  skin,  14;  intracuticular  suture,  15; 
suture  of  muscle,  15;  suture  of  tendons,  16;  suture  of  nerves,  16;  suture 
of  bone  and  cartilage,  16;    suture  of  serous  surfaces,  bowel,  etc.,  17. 

PAET  II. 
Head  and  Face 20-122 

Head:  Surgical  anatomy  of  the  head,  20;  of  the  scalp,  20;  of  the  skull, 
21;  of  the  dura  mater,  22;  of  the  pia  mater,  24. — Operations  upon  the 
Head:  Trephining,  24;  for  depressed  fracture  of  the  skull,  24;  for  intra- 
cranial hemorrhage,  26;  craniectomy  (linear  craniotomy),  30;  trephining 
of  frontal  sinus,  31. — Middle  Fossa  of  the  Skull:  Anatomy  of  the  middle 
fossa,  32;  extirpation  of  Gasserian  ganglion  (Hartley-Krause),  37;  Cush- 
ing,  41;  Rose-Andrews,  42.— Mastoid  Region  and  Ear:  Surgical  anatomy 
of  mastoid  region,  45;  anatomy  of  the  ear,  47. — Operations  upon  the  Mas- 
toid, etc.:  "Wilde's  incision,  52;  drilling  into  antrum,  52;  to  open  and 
drain  antrum,  52;  for  thrombosis  sigmoid  sinus,  54;  for  cerebellar 
abscess,  56;  for  extradural  abscess  in  middle  fossa,  56;  for  temporo- 
sphenoidal  abscess,  57.— Face:  Surgical  anatomy  of  face,  57;  of  skeleton 
of  face,  58;  of  mouth,  60;  side  of  face,  64;  pterygo-maxillary  region,  64. — 
Operations  upon  Face:  Resection  of  upper  jaw,  70;  total  resection  of 
both  superior  maxillae,  75;  to  drain  antrum  of  Highmore,  75;  resection 
of  half  of  lower  jaw,  76;  resection  of  half  of  body  of  lower  jaw,  79;  re- 
section of  entire  body  of  lower  jaw,  81 ;  resection  of  part  of  body  of  lower 
jaw  (in  continuity),  81;  resection  of  part  of  body  of  lower  jaw  (not  in  con- 
tinuity), 82;  resection  of  temporo-maxillary  articulation,  82;  division  of 
second  and  third  branches  of  trifacial  nerve  (Kronlein-Lucke),  83;  opera- 
tions upon  the  peripheral  branches  of  the  trifacial  nerve,  85.— Congenital 
Deformities  of  Face:  Development  of  face,  85;  formation  of  palate,  93; 
teeth,  94;  tongue,  94;  deformities  of  face,  94;  deformities  in  which  fron- 
tal plate  is  concerned,  96;  lateral  clefts  of  the  upper  lip,  and  alveolar 
process  and  cleft  palate,  96;  median  clefts  and  notches  of  the  upper  lip, 
100;  lateral  nasal  clefts,  101;  oblique  facial  clefts,  101;  deformities  in 
which  the  first  visceral  arch  is  concerned,  103;  transverse  facial  clefts, 
103;  median  clefts  of  lower  lip,  lower  jaw,  and  tongue,  103.— Operations 
for  Harelip,  Cleft  Palate,  etc.:    Operations  for  harelip,  103;    operations  for 


yi  CONTENTS. 

incomplete  harelip,  105;  operations  for  complete  harelip,  107;  operations 
for  single  complete  harelip  with  cleft  of  alveolar  process  and  advance- 
ment of  the  intermaxillary  bone,  109;  operation  for  double  harelip  without 
a  prominent  advanced  intermaxillary  bone,  109;  operation  for  double 
harelip  with  prominent  advanced  intermaxillary  bone,  109;  operation  for 
cleft  palate,  112. — Operations  upon  the  Lips:  Excision  of  whole  lower  lip, 
116;  restoration  of  lower  lip,  117;  Dieffenbach-Jaesche,  117;  Bruns,  118; 
Langenbeck,  119;  Estlaender,  120;  restoration  of  upper  lip,  121; 
Estlaender,  121;    Dieffenbach's  Wellenschnitt,  121;    Bruns,  122. 

PAET  III. 
Neck  and  Tongue 123-178 

Surgical  Anatomy  of  Neck:  Deep  cervical  fascia,  123;  back  of  the  neck, 
125;  side  of  the  neck,  125;  anterior  triangle,  127;  posterior  triangle,  127; 
sterno-mastoid  region,  128;  inferior  carotid  triangle,  128;  superior  carotid 
triangle,  130;  submaxillary  triangle,  131;  lingual  triangle,  132;  occipital 
triangle,  132;  subclavian  triangle,  133;  front  of  the  neck,  134;  hyoid 
bone,  135;  suprahyoid  region,  135;  infrahyoid  region,  135;  laryngeal  re- 
gion, 138;  thyroid  gland,  139;  suprasternal  region,  140;  blood-vessels  of 
the  neck,  141;  common  carotid  artery,  141;  internal  carotid  artery,  142; 
external  carotid  artery,  143;  internal  jugular  vein,  144;  subclavian  artery, 
145;  inferior  thyroid  artery,  146;  vertebral  artery,  146.— Operations  upon 
the  Neck:  Tracheotomy,  147;  tampon  of  trachea,  147;  high  tracheotomy, 
148;  low  tracheotomy,  149;  median  tracheotomy,  150;  transverse  laryn- 
gotomy,  151;  thyrotomy,  151;  laryngectomy,  153;  extirpation  of  half  of 
the  larynx,  157;  for  goiter,  157;  external  oesophagotomy,  161;  ligation  of 
blood-vessels,  162;  common  carotid  artery,  162;  external  carotid  artery, 
164;  internal  carotid  artery,  165;  subclavian  artery,  165;  lingual  artery, 
167;  inferior  thyroid  artery,  168;  cervical  sympathetic,  169. — Operations 
upon  the  Tongue:  Amputation  of  tongue  (Kocher),  172;  amputation  of 
tongue  (Regnoli-Billroth),  174;  extirpation  of  tongue  through  floor  of 
mouth  with  division  of  lower  jaw,  175;  Sedillot,  175;  Langenbeck,  176; 
Billroth,  177;    extirpation  of  half  of  the  tongue  (Whitehead),  177. 

PAET  IV. 
Thorax  179-220 

Surgical  Anatomy  of  Thoracic  Wall:  Skeleton  of  thorax,  179;  muscles  of 
chest  wall,  182;  fasciag  of  chest,  182;  internal  mammary  artery,  183; 
diaphragm,  184.— Regions  of  Chest:  Sternal  region,  185;  upper  anterior 
pectoral  region,  185;  clavicular  region,  186;  infraclavicular  region,  187; 
mammary  region  (breast),  188;  lower  anterior  pectoral  region,  190;  lat- 
eral pectoral  region,  190. — Mediastinum  and  Contents:  Pericardium,  191; 
heart,  192;  thymus,  195;  arch  of  aorta,  195;  pneumogastric  nerves,  196; 
phrenic  nerves,  197;  trachea,  197;  oesophagus,  198;  thoracic  aorta,  200; 
vena  azygos,  200;  vena  hemiazygos,  201;  thoracic  duct,  201;  innominate 
artery,  201;  left  common  carotid  and  subclavian  arteries,  201. — Pleura: 
Limits  of  pleura  indicated  by  lines  upon  chest  wall,  202;  anterior  edge  of 
pleura,  202;  lower  edge  of  pleura,  203;  dome  of  pleura,  204.— Lungs: 
Root  of  lung,  205;  lung,  206. — Operations  upon  the  Chest:  Incisions  for 
abscess  of  breast,  207;  extirpation  of  tumors  (fibroids)  from  mammary 
gland,  208;  amputation  of  breast,  208;  amputation  of  breast  (Halsted- 
Meyer),  210;  ligation  of  intercostal  artery,  213;  ligation  of  internal  mam- 
mary artery,  213;  paracentesis  pericardii,  214;  pericardiotomy,  214;  peri- 
cardiorrhaphy,  215;  cardiorrhaphy,  215;  thoracentesis,  217;  thoracotomy, 
218;    thoracectomy  (Estlaender),  219;    pleurectomy  (Fowler),  219. 


CONTENTS.  vii 

PART  V. 
Abdomen  and  Back 221-396 

Abdomen:  Diaphragm,  221;  posterior  wall  of  the  abdomen,  222;  antero- 
lateral wall  of  the  abdomen,  223;  superficial  vessels  of  abdominal  wall, 
224;  muscles  of  the  antero-lateral  wall,  224;  fascia  transversalis,  227; 
parietal  peritoneum,  227;  deep  vessels  of  abdominal  wall,  228;  regions  of 
the  abdomen,  229.— The  Back:  Muscles  of  the  back,  231;  erector  spinse 
muscle,  232;  quadratus  lumborum  muscle,  233;  lumbar  fascia,  233;  psoas 
and  iliacus  muscles,  234;  spinal  column,  etc.,  234.— The  Stomach:  Sur- 
gical anatomy  of  the  stomach,  237. — Operations  upon  the  Stomach:  Plica- 
tion of  the  gastro-hepatic  ligaments  (Beyea),  241;  gastroplication,  243; 
infolding  of  wall  of  stomach  for  ulcer,  246;  gastrotomy,  246;  pyloroplasty 
(Heinecke  and  Mikulicz),  252;  (Finney),  253;  gastrostomy,  255;  von 
Hacker,  255;  Ssabanajew  and  Franck,  257;  Witzel,  259;  Kader,  261;  gas- 
trorrhaphy,  262;  gastroplasty,  263;  gastro-gastrostomy,  264;  gastrect- 
omy, 266;  partial  atypical  gastrectomy,  266;  partial  cylindrical  gastrect- 
omy, 267;  pylorectomy,  267;  Billroth,  267;  Kocher,  271;  Hartmann  gas- 
trectomy, 274;  Mayo,  278;  complete  gastrectomy,  280.— The  Small  In- 
testine: Surgical  anatomy  of  the  small  intestine,  284. — Operations  upon 
the  Small  intestine:  Enterorrhaphy,  288;  enterectomy,  293;  end-to-end 
anastomosis,  296;  suture,  296;  Mounsell's,  297;  Connell  suture,  300; 
Murphy  button,  303;  Laplace  forceps,  305;  O'Hara  forceps,  307;  side-to- 
side,  lateral  approximation,  310;  suture,  310;  Murphy  button,  311;  with 
McGraw  rubber  suture,  312;  Laplace  forceps,  312;  O'Hara  forceps,  312; 
gastro-enterostomy,  312;  gastro-duodenostomy,  313;  gastrojejunostomy, 
313;  anterior  (Woelfler),  313;  posterior  (von  Hacker),  317;  with  Murphy 
button,  320;  with  McGraw  rubber  suture,  321;  with  Laplace  forceps,  324 
with  O'Hara  forceps,  324;  without  a  loop  (Czerny),  325;  Roux,  326 
jejunostomy  (Maydl),  328. — Large  Intestine  and  Vermiform  Appendix 
Surgical  anatomy  of  the  large  intestine,  etc.,  329;  cascum,  329;  vermi- 
form appendix,  329;  ascending  colon,  331;  transverse  colon,  332;  descend- 
ing colon,  332;  sigmoid  flexure,  332;  blood  supply  of  large  intestine,  332. 
— Operations  upon  Large  Intestine:  Colostomy,  333;  Maydl  method,  336; 
resection  of  caecum,  338;  end-to-end  anastomosis,  339;  lateral  anastomo- 
sis, 340;  end-to-side,  lateral  implantation,  341;  ilio-colostomy,  331;  re- 
section of  sigmoid  flexure,  342.— Operations  upon  Vermiform  Appendix: 
Appendicectomy,  343;  McBurney  incision,  344;  Battle  incision,  344;  lig- 
ature without  inversion,  347;  inversion  of  stump  without  ligature,  347; 
inversion  of  stump  with  purse-string  (Dawbarn),  347;  inversion 
(Edebohls),  348;  for  appendicular  abscess,  349;  for  appendicitis  accom- 
panied by  general  peritoneal  infection,  353;  appendicostomy,  354. — Liver 
and  Gall-bladder:  Surgical  anatomy  of  liver,  354;  surgical  anatomy  of 
gall-bladder  and  bile-ducts,  356. — Operations  upon  Liver:  Hepatotomy, 
359;  hepatectomy,  360;  injuries  to  liver,  360;  omentopexy  (Talma),  360. — 
Operations  upon  Gall-bladder:  Aspiration  of  gall-bladder,  362;  chol- 
ecystotomy,  362;  cholecystostomy,  365;  with  uncontracted  gall-bladder, 
365;  with  contracted  gall-bladder,  368;  cholecystectomy,  369;  cholecysto- 
jejunostomy,  371;  cholecysto-duodenostomy  with  Murphy  button,  372; 
cholecysto-colostomy,  374. — Operations  upon  Gall-ducts:  Choledochotomy, 
375;  choledocho-lithectomy,  375;  choledocho-lithotripsy,  377;  removal  of 
calculi  from  common  duct  through  duodenum,  377. — Pancreas:  Surgical 
anatomy  of  pancreas,  379.— Operations  upon  Pancreas:  Fat-necrosis, 
382;  for  injuries,  383;  for  cysts,  384;  for  acute  pancreatitis,  385;  for 
tumors,  386. — Spleen:  Surgical  anatomy  of  spleen,  387. — Operations  upon 
Spleen:  splenotomy,  388;  splenorrhaphy,  389;  splenopexy,  389;  splenec- 
tomy, 390. — Operations  upon  Spinal  Column:  Laminectomy,  391;  lumbar 
puncture,  393. 


yiii  CONTENTS. 

PART  VI. 
The  Rectum 397-420 

Surgical  anatomy  of  the  rectum,  397;  sacrum,  397;  coccyx,  398;  rectum, 
398. — Operations  upon  the  Rectum:  Dilatation  of  the  sphincter,  401 
fistula  in  ano,  401;  for  complete  fistula,  402;  for  incomplete  fistula,  403 
hemorrhoids,  403;  ligation  and  excision,  404;  clamp  and  cautery,  405 
excision  of  part  of  rectal  wall,  405;  innocent  rectal  polypi,  407;  extirpa- 
tion cf  rectum  (Volkmann),  407;  resection  of  rectum  (Dieffenbach),  410; 
resection  and  amputation  of  rectum  through  sacral  route  (Kraske),  412; 
for  resection  of  rectum,  412;    for  amputation  of  rectum,  420. 

PART  VII. 
Hernia,  Spermatic  Cord,  Testes,  etc 421-465 

Surgical  anatomy  of  groin,  421;  superficial  layer  of  superficial  fascia,  421; 
lymphatic  glands,  422;  deep  layer  of  superficial  fascia,  422;  inguinal  re- 
gion, 422;  descent  of  the  testes,  428;  femoral  region,  431;  study  of  in- 
guinal and  femoral  region  from  within  the  abdomen,  434;  inguinal  region, 
434;  femoral  region,  437. — Operations  for  Hernia:  Herniotomy,  439;  for 
inguinal  hernia  (Bassini),  442;  for  inguinal  hernia  (Halsted),  448;  for 
femoral  hernia,  451;  for  undescended  testes,  452. — Spermatic  Cord,  Scro- 
tum, etc.:  Spermatic  cord,  456;  scrotum,  457;  testes,  457;  ejaculatory 
ducts,  458. — Operations  upon  Spermatic  Cord,  Scrotum,  etc.:  For  varico- 
cele, 458;    for  hydrocele,  460;    castration,  464. 

PART  VIII. 
Urinary  System 466-506 

Kidneys:  Surgical  anatomy  of  kidney,  466. — Operations  upon  the  Kid- 
ney: Nephropexy,  467;  nephropexy  (Edebohls),  470;  nephrotomy,  473; 
nephrolithotomy,  474;  nephrectomy,  474;  decortication  of  kidney  (Ede- 
bohls), 475.— Bladder:  Surgical  anatomy  of  bladder,  476.— Operations 
upon  Bladder:  Suprapubic  cystotomy,  478;  puncture  of  bladder,  481. — 
Penis:  Surgical  anatomy  of  the  penis,  481. — Operations  upon  the  Penis: 
Forcible  dilatation  of  prepuce,  482;  dorsal  section,  482;  circumcision,  484; 
circumcision  with  clamp,  485;  amputation  of  penis,  485. — Perineum  and 
Ischio-rectal  Region:  Floor  of  pelvis  from  without,  487;  ischio-rectal 
region,  488;  perineum,  489;  pelvic  cavity  from  within,  491. — Operations 
upon  Perineum,  etc.:  Perineal  section  with  a  guide,  493;  perineal  sec- 
tion without  a  guide,  494;  median  lithotomy,  495;  lateral  lithotomy,  496. — 
Prostate:  Surgical  anatomy  of  prostate,  496. — Operations  upon  Prostate: 
Prostatectomy,  499;  suprapubic  prostatectomy,  499;  perineal  prostatec- 
tomy, 500;    method  of  Young,  503;    prostatotomy  (Bottini),  504. 

PART  IX. 
The  Upper  Extremity 507-550 

The  Axilla:  The  axilla,  507;  the  axillary  artery,  507.— The  Arm:  Vessels 
of  the  arm,  510;  the  brachial  artery,  510;  the  radial  artery,  512;  the 
ulnar  artery,  513;  musculo-spiral  nerve,  514;  median  nerve,  514;  ulnar 
nerve,  514. — The  Hand:  Nerve-supply  of  the  hand,  515;  ligations,  515; 
axillary,  515;  brachial,  516;  radial,  518;  ulnar,  518.— Amputations,  Re- 
sections, etc.:  Surgical  anatomy  of  hand,  518;  phalango-phalangeal  joints, 
518;  metacarpo-phalangeal  joints,  519;  exarticulation  of  the  finger  at  the 
phalango-phalangeal  joint,  519;  exarticulation  of  finger  at  the  met- 
acarpo-phalangeal joint,    521;     exarticulation  of  hand  at  the  carpo-met- 


CONTENTS.  ix 

acarpal  articulation,  522;  surgical  anatomy  of  wrist- joint,  524;  exarticu- 
lation  of  hand  at  wrist-joint,  525;  amputation  through  forearm,  526; 
surgical  anatomy  of  elbow-joint,  527;  exarticulation  of  forearm  at  elbow- 
joint,  529;  amputation  of  arm,  530;  surgical  anatomy  of  shoulder- joint, 
532;  exarticulation  at  shoulder-joint  (Spence),  534;  exarticulation  at 
shoulder-joint  (Esmarch),  536;  exarticulation  at  shoulder-joint  with 
deltoid  flap,  538.— Resections:  Wrist- joint,  541;  elbow  (Langenbeck),  543; 
shoulder,  545;  tendon  suture,  548;  nerve  suture,  548;  intravenous  saline 
infusion,  549. 

PAET  X. 
Lower  Extremity 551-617 

Thigh:  Gluteal  region,  551;  stretching  sciatic  nerve,  552;  anterior  femoral 
region,  554;  internal  saphenous  vein,  554;  femoral  artery,  555;  anterior 
crural  nerve,  557;  ligation  of  femoral  artery,  557;  popliteal  space,  560. 
— Leg:  Anterior  tibial  artery,  561;  anterior  tibial  nerve,  562;  ligation 
of  anterior  tibial  artery,  562;  posterior  tibial  artery,  562;  posterior  tibial 
nerve,  564;  ligation  of  posterior  tibial  artery,  564;  tenotomy,  564;  multiple 
ligature  of  veins  of  leg,  565. — Amputations,  Resections,  etc.:  Surgical 
anatomy  of  skeleton  of  foot,  566;  exarticulation  of  big  toe,  568;  exar- 
ticulation of  big  toe  with  removal  of  first  metatarsal,  568;  exarticulation 
of  little  toe,  568;  for  ingrowing  toe-nail,  569;  amputation  through  tarso- 
metatarsal articulation  (Lisfranc),  569;  amputation  through  medio-tarsal 
articulation  (Chopart),  572;  surgical  anatomy  of  ankle-joint,  573;  exar- 
ticulation of  foot  at  ankle-joint  (Syme),  574;  exarticulation  of  foot,  etc. 
(Pirogoff),  575;  amputation  of  leg,  578;  amputation  of  leg  with  lateral 
hooded  flaps,  578;  surgical  anatomy  of  knee-joint,  581;  exarticulation  of 
leg  at  knee-joint  (Stephen  Smith),  584;  transcondylar  amputation  (Car- 
den),  586;  amputation  of  knee  (Gritti-Stokes),  588;  amputation  of  thigh, 
589;  surgical  anatomy  of  hip- joint,  591;  exarticulation  of  thigh  at  hip 
(Wyeth),  594;  exarticulation  of  thigh  with  preliminary  ligation  of  com- 
mon femoral,  597.— Resections:  Ankle  (Langenbeck-Hueter),  597;  ankle 
(Koenig),  601;  ankle  (Lauenstein),  603;  ankle,  osteoplastic  (Mikulicz- 
Wladimirow),  604;  knee-joint,  606;  hip-joint  (Langenbeck),  611;  osteot- 
omy, 615;    suture  of  patella,  616. 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Division   of   Skin   by  Transfixion 6 

2.  Esmarch  Bandage  and  Constrictor 7 

3.  Trendelenburg     Position 10 

4.  Square    Knot 13 

5.  Slip    Knot 13 

6.  Surgeon's     Knot 13 

7.  Intracuticular     Suture 15 

8.  Bone-drill    16 

9,10.    Segment  of  Bowel— Lembert  Sutures 17 

11.  Cushing   Suture    18 

12.  Halsted  Suture   18 

13.  Hartley    Chisel    27 

14.  Temporary  Resection  of  Skull 28 

15.  Base  of  Skull  from  Within 33 

16.  Section  Through  Floor  of  Middle  Fossa 36 

17.  Zygomatic   Arch  Resected   (Cushing) 41 

18.  Incisions  for  Resection  of  Gasserian  Ganglion 43 

19.  Side   of   Skull 47 

20.  Pterygo  maxillary  Region 67 

21.  Pterygo-maxillary  Region    (deep) 68 

22.  Incisions  for  Resection  of  Upper  Jaw 71 

23.  Resection  of  Upper  Jaw 73 

24.  Transverse  Section  of  Head  End  of  Embryo  Twelve  Days  Old 86 

25.  Sagittal  Section  of  Head  End  of  Embryo  Twelve  Days  Old 86 

26.  Face  of  Embryo,  Fifth  Week 88 

27.  Face  cf  Embryo,  Fifth  Week 89 

28.  Embryo,  Fourth  Week,  Seen  from  Side 90 

29.  Embryo,  Eighth  Week,   Seen  from  Side 91 

30.  Face  cf  Embryo,  about  Eighth  Week 93 

31.  Diagram  of  Congenital  Facial  Clefts 95 

32.  Double    Complete    Harelip 97 

33.  Harelip  with  Advanced  Intermaxillary  Portion 98 

34.  Double  Cleft  Palate  with  Advanced  Intermaxillary   Portion 99 

35.  Oblique   Facial   Cleft 101 

36.  Incomplete  Oblique  Facial   Cleft 102 

37.  Transverse   Facial    Cleft 102 

38.  39.     Simple  Paring  for  Incomplete  Harelip 105 

40,  41.    Von   Graefe   Operation  for  Incomplete  Harelip 105 

42,  43,  44.    Nelaton   Operation  for  Incomplete  Harelip 106 

45,  46,  47.    Malgaigne  Operation  for  Incomplete  Harelip 106 

48,  49,  50.    Mirault  Operation  for  Incomplete  Harelip 107 

51.  Wellenschnitt  for  Complete  Harelip 108 

52,  53,  54.    Hagedorn  Operation  for  Single  Complete  Harelip 108 

55,  56,    57.    Double  Malgaigne  Operation  for  Double  Complete  Harelip 110 

58,  59,  60. — Hagedorn  Operation  for  Complete  Double  Harelip 110 

61.  Whitehead   Gag 113 

62.  Repair  of  Cleft  Palate 116 

63.  Excision  of  Entire  Lower  Lip 117 

64.  Triangular  Defect  in  Lower  Lip  Closed 117 

65.  Dieffenbach-Jaesche  Operation  for  Restoring  Lower  Lip 118 

66.  67.    Bruns  Method  of  Restoring  Lower  Lip 119 

68,  69.    Langenbeck  Method  of  Restoring  Lower  Lip 119 

70,  71.    Estlaender  Method  of  Restoring  Lower  Lip 120 


(Xi) 


xii  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

72,  73.    Dieffenbach  Wellenschnitt  for  Restoration  of  Upper  Lip 121 

74,  75.    Brims  Method  of  Restoring  Upper  Lip 121 

76.  Section  through   Neck   124 

77.  Side  of  Neck  to   Show  Triangles 129 

78.  Front    of    Neck 138 

79.  Tracheotomy    Tube 147 

80.  Trendelenburg    Tampon    Cannula 147 

81.  Incision  for  Removal  of  Lower  Jaw,  etc 163 

82.  Transverse   Section  Through   Thorax 191 

83.  Outline  of  Heart,   etc 194 

84.  85,  86.    Outline  of  Pleura,   etc 202 

87.  Section  Through  Seventh,  Eighth,  and  Ninth  Ribs 204 

88.  Amputation  of  Breast 211 

89.  Transverse  Section  of  Abdomen 226 

90.  Transverse   Section  of  Abdomen 226 

91.  Regions    of    Abdomen 228 

92.  Sagittal  Section  to  Show  Arrangement  of  Greater  and  Lesser  Omenta 239 

93.  Stomach  Showing  Arteries,   Lymphatics,   etc 240 

94.  Incisions  to  Reach  Abdominal  "Viscera  242 

95.  Plication  of  Gastro-hepatic  Ligament 243 

96.  Gastroplication 244 

97.  Cross  Section  of  Stomach  after  Gastroplication 245 

98.  Cross  Section  of  Stomach  after  Gastroplication 245 

99.  Posterior  Wall  of  Stomach  Pushed  Through  Incision  in  Anterior  Wall 249 

100,  101.    Pyloroplasty    (Heineclte-Mikulics) 252 

102,  103,  104,  105.    Pyloroplasty    (Finney)    254 

106,  107.    Gastrostomy    (Ssahanajew-Franck) 257 

108,  109.     Gastrostomy     (Witzel) 260 

110,  111,  112.    Gastrostomy     (Kader) 262 

113.  Gastro- gastrostomy     265 

114.  Pylorectomy    268 

115.  Pylorectomy    (Billroth)    269 

116.  Pylorectomy    (Billroth)    270 

117.  Pylorectomy    (Kocher)    273 

118.  Doyen    Compression    Forceps 275 

119.  Hartmann   Compression  Forceps 275 

120.  Gastrectomy    (Hartmann) 276 

121.  Gastrectomy    (Schlatter) 282 

122.  Section  of  Intestine,  etc.      "Dead  Space." 286 

123.  Blood    Supply    Small    Intestine 286 

124.  Intestine   Compressor    293 

125.  Bnterectomy    294 

126.  Suture  to  Obliterate  "Dead  Space" 297 

127.  Suture  to  Obliterate  "Dead  Space,"  tied 297 

128.  129,  130.     End-to-Bnd  Anastomosis  (Hounsell)    299 

131,  132,  133.     Connell    Suture    300 

134.  Connell   Suture,    Tying  Knot 302 

135.  Bnd-to-End  Anastomosis  (Murphy  Button) 304 

136.  Murphy   Button    304 

137.  138,  139.     Laplace   Anastomosis    Forceps 306 

140,  141,  142.     O'Hara  Anastomosis  Forceps 308 

143.  End-to-End  Anastomosis   (O'Hara) 308 

144.  Lateral   Anastomosis    310 

145.  Lateral  Anastomosis  (Murphy  Button) 310 

146.  Gastrojejunostomy    ("Vicious    Circle") 314 

147.  Gastrojejunostomy    (Jaboulay-Braun)    ., 318 

148.  Posterior    Gastrojejunostomy 318 

149.  Gastrojejunostomy    (McGraw    Rubber   Suture) 322 


LIST  OF  ILLUSTRATIONS.  xiii 

FIG.             >  .                                                                                                                                                              PAGE 

150.  Posterior    Gastrojejunostomy    (Vzerny) 326 

151.  Posterior    Gastrojejunostomy    (Roux) 327 

152.  Colostomy     335 

153     Colostomy    (Maydl)    336 

154.  Colostomy     337 

155.  Colostomy   {Maydl)    337 

156.  Appendix     346 

157.  Appendicectomy    346 

158.  Appendicectomy    348 

159.  Bile-ducts,   etc 358 

160.  Cholecystostomy    366 

161.  Cholecystostomy    368 

162.  Cholecysto-duodenostomy    (Murphy   Button) 373 

163.  Orifices  of  Common  Bile-duct  and  Pancreatic  Duct 380 

164.  Orifices  of  Common  Bile-duct  and  Pancreatic  Duct 380 

165.  Keen   Bone   Forceps 392 

166.  Lumbar   Puncture    395 

167.  Complete  Fistula  in  Ano 402 

168.  Blind  Internal   Fistula 402 

169.  Blind   External    Fistula 402 

170.  Hemorrhoids    404 

171.  Incision  for  Resection  of  Rectum   (Eraske) 413 

172.  Ilium  and  Sacrum   (Eraske) 414 

173.  Resection  of  Rectum   {Eraske)- 416 

174.  Resection  of  Rectum   {Eraske) 416 

175.  Resection  of  Rectum   (Eraske) .' 419 

176.  Inguinal  and  Femoral  Regions 422 

177.  Inguinal   Canal 424 

178.  Descent  of  Testis 428 

179.  Inguinal  Region   43C 

180.  Inguinal   Region,    Congenital   Hernia 430 

181.  Inguinal  Region,  Acquired  Hernia  430 

182.  Superficial   Femoral   Region 432 

183.  Superficial   Femoral   Region — Femoral   Sheath 432 

184.  Pelvis  and  Ligaments  of  Ilio-pubic  (or  Femoral)  Region   434 

185.  Femoral    Space    434 

186.  Deep  Femoral  Region  435 

187.  Inguinal  and  Femoral  Regions  from  Within  Abdomen 436 

188.  Irregular  Origin  of  Obturator  Artery 440 

189.  Irregular  Origin  of  Obturator  Artery 441 

190.  Operation  for  Inguinal  Hernia 443 

191.  Bass.ni  Operation  for  Inguinal  Hernia 444 

192.  Bassini   Operation    446 

193.  Halsted's  Operation  for  Hernia 450 

194.  Operation  for  Femoral  Hernia 452 

195.  For  Undescended   Testis 454 

196.  For  Undescended   Testis 454 

197.  For  Undescended   Testis 455 

198.  For   Undescended   Testis 455 

199.  Spermatic   Cord 458 

200.  Cross  Section  of  Spermatic  Cord 458 

201.  Exposure  of  Spermatic   Cord 458 

202.  Varicocele    459 

203.  Varicocele    460 

284.    Hydrocele,    Tapping   461 

205.  Volkmann  Operation  for  Hydrocele 462 

206.  Hydrocele,  Retroversion  of  Tunica  Vaginalis 463 

207.  Castration    464 


xiv  LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

208.  Inc'sion  to  Expose   Kidney 468 

209.  Nephropexy   (Edebohls)    472 

210.  Relations  of  Peritoneum  to  Bladder 478 

211.  Dorsal    Section    (Roser) 483 

212.  Circumcision    484 

213.  214.    Amputation  of   Penis 486 

215.  Perineum  and  Ischio-rectal  Region 489 

216.  Transverse   Section   of  Prostate 498 

217.  Perineal    Prostatectomy 502 

218.  Young's  Tractor,   Closed 504 

219.  Young's   Tractor,    Open 504 

220.  Perineal    Prostatectomy    {Young) 504 

221.  Axillary   Region    508 

222.  Section  Through  Middle  of  Right  Arm 510 

223.  Section  Through  Middle  of  Right  Forearm 512 

224.  Right  Arm,   Incision,   etc 517 

225.  Exarticulation    of    Finger 520 

226.  Exarticulation  of  Finger  521 

227.  Palmar  Aspect  of  Right  Hand 523 

228.  Dorsal  Aspect  of  Right  Hand 523 

229.  Stump  After  Exarticulation  of  Hand 524 

230.  Right  Arm,   Anterior  Aspect 531 

231.  Right  Shoulder,  Anterior  View 535 

232.  Right  Shoulder,  Posterior  View 537 

233.  Left  Shoulder,  Side  View 538 

234.  Left  Arm,  Posterior  View 540 

235.  Resection    of    Wrist-joint 541 

236.  Tendon     Suture 548 

237.  Superficial  Vein  Exposed  for  Saline  Infusion 549 

238.  Stretching  Sciatic  Nerve 553 

239.  Section  Through  the  Middle  of  the  Right  Thigh 556 

240.  Ligation  of  Femoral  Artery 558 

241.  Section  Through  the  Middle  of  the  Right  Leg 562 

242.  Right  Foot  566 

243.  Operations  for  Ingrowing  Toe-nail 569 

244.  Right  Foot,   Inner  Side 571 

245.  Right  Foot,   Outer  Side 571 

246.  Right  Foot,  Inner  Side  (Pirogoff's  Amputation) 576 

247.  Right  Foot,  Inner  Side  (Giinther's  Modification) 576 

248.  Right  Foot,  Inner  Side  (Le  Fort's  Modification) 576 

249.  Amputation    of    Leg 579 

250.  Right  Leg,   Outer  Side 585 

251.  Right  Leg  (Carden's  Amputation) 587 

252.  Stump  After   Carden's  Amputat'on 587 

253.  Gritti-Stokes   Amputation    589 

254.  Exarticulation    at    Hip- joint 595 

255.  Right  Foot,  Outer  Side  (Langenbeclc-Hueter) 598 

256.  Right  Foot,  Inner  Side  (Langenbcck-Hueter) 598 

257.  Incisions  for  Resection  of  Ankle  (Koenig)  and  for  Amputation  of  Big  Toe  with 

Removal  of  the  First  Metatarsal 601 

258.  Resection  of  Ankle-joint  (Lauenstein's  Incision) 604 

259.  Incision  for  Mikulicz-Wladimirow  Osteoplastic  Resection  of  the  Ankle-joint 605 

260.  Right  Leg,   Inner  Side 607 

261.  Resection    of    Knee-joint 609 

262.  Resection  of  Hip   (Langenbeck's  Incision) 612 

263.  Resection  of  Hip  (Anthony  White's  Incision) 613 

264.  Osteotomy   (Macewen)    615 

265.  Wiring   Patella  for  Fracture 617 


PART    I. 

GENERAL    CONSIDERATIONS. 


AN/ESTHESIA. 

General  Anaesthesia.  —  Of  the  general  anaesthetics,  ether  and 
chloroform  are  the  ones  most  commonly  employed.  Ether  is  used 
more  generally  than  chloroform,  especially  in  this  part  of  the  United 
States.  With  ether,  the  stage  of  excitement  and  struggling  that 
precedes  the  stage  of  anaesthesia  is  more  prolonged  and  more  pro- 
nounced than  with  chloroform;  still,  this  objection  may  be  partially 
eliminated  by  administering  nitrous  oxide  or  chloroform  until  the 
period  of  excitement  has  been  passed.  The  preliminary  use  of 
nitrous  oxide  is  much  in  vogue  at  present. 

Ether  stimulates  the  heart  and  increases  the  arterial  tension. 
It  has  a  marked  congestive  influence  upon  the  kidneys,  and  acts  as 
an  irritant  to  the  respiratory  tract. 

The  first  stage  of  chloroform  narcosis  is  shorter  than  is  that 
of  ether  and  is  not  accompanied  by  as  much  excitement  and  strug- 
gling. Chloroform  does  not  increase  the  arterial  tension  and  does 
not  congest  the  kidneys,  but  it  has  a  tendency  to  interfere  with  the 
heart-action,  especially  if  the  heart-muscle  is  diseased  and  in  con- 
ditions accompanied  by  chronic  anaemia.  Therefore,  if  it  become  a 
matter  of  choice,  one  should  elect  ether  if  the  heart-action  is  un- 
satisfactory or  if  the  patient  is  markedly  anaemic,  and  chloroform  if 
the  urine  shows  defective  kidneys  or  if  there  is  a  tendency  to  cere- 
bral apoplexy  or  pulmonary  disease  and  in  cases  of  empyema.  Chlo- 
roform is  also  preferable  to  ether  in  young  children  and  in  very  old 
people.  Alcoholics,  as  a  rule,  take  chloroform  much  more  satisfac- 
torily than  ether. 

In  operations  about  the  mouth  where  the  mask  can  only  be 
applied  during  intervals,  and  for  administration  through  a  trache- 
otomy tube,  chloroform  is  the  preferable  anaesthetic. 

Mixtures  of  chloroform  and  ether  or  of  alcohol,  chloroform,  and 
ether  have  been  employed  extensively  by  some  surgeons,  but  they  have 
never  come  into  very  general  use.    In  the  chloroform  and  ether  mix- 

•       (1) 


2  GENERAL  CONSIDERATIONS. 

ture  the  proportions  are  2  of  chloroform  and  3  of  ether.  The  propor- 
tions of  the  "A.  C.  E."  mixture  are  1  of  alcohol,  2  of  chloroform,  and 

3  of  ether.  The  mixture  should  be  made  immediately  before  using 
and  should  be  considered  as  chloroform.  It  should  be  administered 
through  an  open  inhaler  or  upon  a  piece  of  lint. 

Nitrous  Oxide,  Laughing  G-as. — When  pure,  this  agent  is  en- 
tirely free  from  irritant  properties.  It  is  supplied  for  anaesthetic 
administration  in  liquid  form  in  iron  cylinders. 

Nitrous  oxide  may  be  emplo3red  as  the  anaesthetic  with  much 
satisfaction  for  short  surgical  operations,  and  also  to  induce  the  first 
stage  of  anaesthesia  preliminary  to  the  use  of  ether.  In  this  way  the 
struggling  and  muscular  spasm,  etc.,  of  the  primary  stage  of  ether 
anaesthesia  are  avoided. 

If  nitrous  oxide  is  employed  as  the  anaesthetic  for  brief  surgical 
operations  or  preliminary  to  ether  administration  it  may  be  used  pure. 
Under  these  circumstances  a  very  brief  period,  from  one-half  to  two 
minutes,  is  required  to  induce  anaesthesia. 

For  surgical  procedures  of  longer  duration  the  administration 
of  the  nitrous  oxide  must  be  interrupted  with  occasional  inspirations 
of  air  or  else  the  gas  must  be  diluted.  It  may  be  administered  pure, 
allowing  occasional  inspirations  of  air, — every  second  or  third  in- 
spiration.— or  else  the  slide  in  the  tube  attached  to  the  mouth-piece 
may  be  kept  partially  open  all  the  time,  thus  permitting  continuous 
entrance  of  the  atmospheric  air  and  admixture  with  the  nitrous  oxide. 
In  this  manner  anaesthesia  with  nitrous  oxide  may  be  continued  for 
from  five  to  ten  minutes.  During  the  nitrous-oxide  anaesthesia  the 
respiration  should  be  regular  and  snoring  and  accompanied  with  only 
a  moderate  degree  of  duskiness. 

Incomplete  General  Anaesthesia. — This  plan  consists  in  admin- 
istering a  liberal  dose  of  morphin  hypodermically,  shortly  before 
commencing  the  operation,  and  then  giving  the  chloroform  up 
to  the  point  of  deadening  the  sensation  without  nullifying  the  re- 
flexes. In  this  way  the  pain  is  made  endurable  and  at  the  same 
time,  the  reflexes  being  still  active,  the  patient  is  able  to  cough,  clear 
the  throat,  and  expectorate.  This  plan  may  be  practiced  with  satis- 
faction in  operations  about  the  upper  and  lower  jaw,  nasal  passages, 
larynx,  etc.,  where  there  is  danger  of  blood  entering  the  respiratory 
canal  and  asphyxiating  the  patient  if  not  coughed  out. 

Local  Anaesthesia. — The  skin  may  be  anesthetized  sufficiently 
for  simple  incision  or  puncture  by  freezing,  either  by  the  application 


ANESTHESIA.  3 

of  ice,  chopped  and  mixed  with  salt,  in  a  bag,   or  by  the  ethyl- 
chloride  spray. 

Ethyl  chloride  is  a  very  volatile  substance,  boiling  at  the  body- 
temperature.  It  is  supplied  in  glass  cylinders  with  a  removable 
brass  cap.  If  the  cylinder  is  held  in  the  hand  for  a  few  moments 
sufficient  heat  is  imparted  to  volatilize  the  fluid  in  the  cylinder, 
which  then  escapes  in  the  form  of  a  fine  spray.  The  spray  is  directed 
against  the  part  to  be  anaesthetized  for  a  few  minutes. 

For  operations  that  require  a  certain  amount  of  dissection  cocain 
in  a  2-per-cent.  solution,  introduced  into  the  skin,  hypodermic-ally, 
is  more  satisfactory.  The  cocain  is  still  more  effective  if  it  can  be 
confined  to  the  part  that  is  to  be  operated  upon  by  constricting  it 
with  a  rubber  elastic  ligature;  for  example,  in  operations  upon  the 
fingers  and  toes  and  for  circumcision,  etc.,  by  placing  an  elastic 
ligature  about  the  root  of  the  part.  The  solution  should  be  thrown 
into  the  deeper  layer  of  the  skin  proper  so  as  to  raise  welts,  and 
not  into  the  loose  tissue  underneath  the  skin,  and  should  be  introduced, 
a  few  drops  at  a  time,  through  several  punctures  along  the  line  of  the 
proposed  incision. 

After  the  first  puncture  and  injection  have  been  made,  the 
needle  should  be  introduced  each  succeeding  time  through  the  skin 
that  has  already  been  anaesthetized ;  ordinarily  from  20  to  30  minims 
of  a  2-per-cent.  solution,  according  to  the  age,  etc.,  of  the  patient, 
may  be  introduced  during  the  course  of  a  single  operation. 

Occasionally  disagreeable  symptoms  of  cardiac  disturbances  due 
to  the  action  of  the  cocain  present  themselves,  especially  if  it  has 
been  introduced  into  a  part  where  the  circulation  cannot  be  inter- 
rupted with  a  constricting  ligature. 

Mucous  surfaces  may  be  anaesthetized  by  applying  a  wad  of  cotton 
saturated  with  the  cocain  solution  direct  to  the  part  for  several  min- 
utes. 

Eucain  is  used  as  a  substitute  for  cocain;  it  is  said  to  have  no 
depressing  influence  upon  the  heart.  From  20  to  40  minims  of  a 
2-per-cent.  solution  may  be  used. 

Schleich  Infiltration  Method. — The  solution  used  contains 
cocain  and  morphin.  It  is  thrown  into  the  skin  with  a  hypodermic, 
as  described  above  for  cocain,  along  the  course  of  the  intended 
incision.  The  solutions  vary  in  strength  according  to  the  amount 
of  cocain  that  they  contain,  and  are  known  as  Nos.  1,  2,  and  3. 


0.2 

gr.  iij 

0.025 

gr-  1- 

0.2 

gr.  i\2 

100.0 

giiif- 

4  GENERAL  CONSIDERATIONS. 

Solution  No.  1. 

Cocain  muriate gra. 

Morphin  muriate gm. 

Sodium  chloride gm. 

Sterile  water c.c. 

This  is  the  strongest  solution.     A  quantity  up  to  6  drams  may 
he  used. 

Solution  No.  2. 

Coeain  muriate gm.      0.1  gr.  iss. 

Morphia  muriate gm.       0.025  gr.  £. 

Sodium  chloride      gm.       0.2  gr.  iij. 

Sterile  waier  .    .    .    .    ; c.c.   100.0  o^s- 

This  is  the  solution  that  is  commonly  used,  and  of  this  a  quan- 
tity up  to  3  ounces  may  be  injected. 


Cocain  muriate  . 
Morphin  muriate 
Sodium  chloride  . 
Sterile  water  .    . 


Solution  No.  3. 

•  ■  gm. 

•  •  gm. 

•  •  gm- 
.    .  c.c. 


0.01 

gr-  h 

0.025 

gr-  h 

0.2 

gr.  ii] 

)0.0 

5iii|. 

No.  3  is  the  weakest  solution,  containing  only  one-tenth  as 
much  cocain  as  No.  2.     A  pint  of  this  solution  can  be  used. 

By  Direct  Injection  into  Nerve-trunks. — This  plan  consists 
in  injecting  cocain  solution,  1/4  of  1  per  cent.,  or  the  Schleich  solu- 
tion, with  the  hypodermic  syringe  directly  into  the  sensory  nerve- 
trunks  that  supply  the  parts  through  which  the  operation  extends. 
The  nerve-trunks  are  injected  individually  as  they  are  encountered 
during  the  course  of  the  operation.  This  method  has  been  applied 
with  much  success,  for  instance,  in  operations  for  the  cure  of  inguinal 
hernia.  The  skin  is  first  anaesthetized  by  the  infiltration  method,  and 
then  after  this  layer  has  been  incised  the  nerves  that  supply  the  parts — 
the  hypogastric  branch  of  the  ilio-hypogastrie,  the  inguinal  branch 
of  the  ilio-inguinal,  and  the  genital  branch  of  the  genito-crural — are 
injected  according  as  they  are  exposed. 

Analgesia  by  Subarachnoid  Injection  of  Cocain,  etc. — A  solu- 
tion of  cocain,  eucain,  etc.,  may  be  thrown  into  the  subarachnoid 
space  with  a  hypodermic  syringe.  ;  This  method  of  inducing  anal- 
gesia was  introduced  by  Bier  and  has  been  recently  practiced  by 
numerous  surgeons  with  varying  degrees  of  satisfaction,  some  dis- 
carding it  after  a  few  trials  and  others  advocating  its  usefulness. 
No  doubt  it  will  prove  of  value  in  certain  cases.  The  method  of  in- 
troducing the  fluid  is  described  elsewhere  (see  "Lumbar  Puncture"). 


DIVISION  OF  THE  TISSUES.  5 

A  1-  or  2-per-cent.  solution  of  cocain,  eucain,  or  tropacocain 
may  be  used. 

If  the  cocain  solution  is  sterilized  by  boiling,  the  potency  of 
the  drug  is  very  much  impaired.  We  may  thus  account  for  some 
of  the  instances  where  the  method  has  failed  to  give  satisfaction.  If 
cocain,  for  example,  is  used,  1/2  grain  or  less  of  the  crystals  of  hydro- 
chlorate  of  cocain  is  placed  in  a  sterile  glass  vessel  and  1  or  2  drams 
of  ether  poured  in;  this  is  stirred  with  a  sterile  glass  rod  until  the 
ether  evaporates,  when  the  residue  is  dissolved  with  sterilized  dis- 
tilled water.     The  solution  is  then  ready  for  injection. 

According  to  Dudley,  the  cocain  may  be  sterilized  by  adding  a 
few  drops  of  chloroform  to  the  crystals  of  the  drug.  After  the  chlo- 
roform evaporates  the  residue  is  dissolved  in  sterile  water. 

Three  to  seven  minutes  usually  elapse  before  the  analgesia 
reaches  the  level  of  the  diaphragm.  The  lower  limbs  and  the  lower 
part  of  the  trunk  first  show  the  analgesic  effect  of  the  drug,  and  this 
gradually  extends  to  the  chest  and  upper  extremities. 

The  analgesic  effect  lasts  from  fifteen  minutes  to  several  hours. 

The  method  may  be  applicable  in  those  cases  where  extreme 
weakness  or  cardiac  or  renal  disease  renders  the  use  of  chloroform 
or  ether  especially  dangerous. 

DIVISION  OF  THE  TISSUES. 

Division  of  the  Soft  Parts.  Bloody  Division  of  the  Soft 
Parts. — The  division  of  the  integument  may  be  accomplished  with 
the  knife  or  scissors,  either  by  direct  incision  or  by  transfixion 
(Fig.  1).  The  deeper  soft  parts  may  be  divided  with  cutting 
instruments  or  by  tearing  with  the  fingers  or  blunt  instruments, 
the  handle  of  the  scalpel,  thumb  forceps,  etc.  This  plan  of  blunt 
dissection  is  especially  serviceable  in  enucleating  encapsulated  tu- 
mors or  lymphatic  nodes  and  in  separating  between  different  layers 
of  tissue  along  the  normal  connective-tissue  planes. 

The  contents  of  hollow  viscera,  serous  spaces,  and  cystic  tumors 
may  be  evacuated  or  withdrawn  in  part  for  the  purpose  of  diagnosis 
b}r  means  of  the  trocar  and  cannula  or  some  form  of  aspirating 
apparatus.  Substances  may  also  be  introduced  into  the  body  through 
cannula?  or  with  some  form  of  syringe. 

Bloodless  Division  of  the  Soft  Parts. — This  result  may  be 
accomplished  with  the  thermocautery,  galvanocautery,  elastic  liga- 
ture, ecraseur,  or  wire  snare,  and  by  the  action  of  corroding  chem- 
icals. 


6 


GENERAL  CONSIDERATIONS. 


Division  of  Bone. — Bones  may  be  divided  through  an  incision 
in  the  soft  parts  with  the  chisel  and  mallet,  bone  forceps,  or  with 
some  form  of  saw, — circular,  chain,  or  wire,  or  with  the  flat  saw; 
with  the  drill,  dental  burr,  or  bone  scoop.  The  De  Vilbiss  forceps  is 
a  very  satisfactory  instrument  for  the  purpose  of  dividing  the  bone 
in  making  large  bone-flaps  in  the  skull.  The  bones  are  covered  with 
an  adherent  vascular  membrane,  the  periosteum,  which  should  be  in- 
cised with  the  knife  and  separated  from  the  bone  with  the  elevator 
before  applying  the  cutting  instruments  to  the  bone. 

The  bone  may  be  divided  without  an  incision  in  the  soft  parts 
— for  the  purpose  of  correcting  deformities,  etc. — either  by  manual 
force  or  by  the  use  of  an  instrument  known  as  the  osteoclast.  The 
osteoclast  consists  of  a  solid   metal  bar  with   two   sliding  bracelets 


Fig    1. — Division  of  1he  Skin  by  Transfixion. 

one  on  either  end  and  between  these  a  brace  which  may  be  raised 
or  lowered  by  means  of  a  screw. 

HEMORRHAGE. 

During  the  course  of  an  operation  the  hemorrhage  must  be 
controlled  in  order  to  minimize  the  loss  to  the  patient  and  to  keep 
the  field  clear  for  proper  work. 

Hemorrhage  may  be  described  as  capillary,  venous,  and  arterial. 

Capillary  hemorrhage  is  characterized  by  a  general  oozing. 

Venous  hemorrhage  is  characterized  by  a  steady  welling  of 
blood  into  the  wound,  often  filling  it  so  as  to  obscure  the  bleeding 
point.  Venous  blood  is  rather  darker  in  color  than  arterial  blood. 
If  a  large  vein  is  divided  close  to  the  trunk, — i.e.,  in  the  nock  or 
axilla, — or  if  one  of  the  intracranial  dura  mater  sinuses  is  opened, 
the  blood  may  escape  in  a  remittent  stream,  synchronous  with  the 
respiratory  movements,  diminishing  or  ceasing  during  inspiration 
and  increasing  during  expiration.     During  inspiration,  under  these 


HEMORRHAGE.  7 

circumstances,  air  may  be  sucked  into  the  veins,  but,  if  limited  in 
quantity,  this  is  said  to  do  no  harm;  nevertheless  it  should  be 
guarded  against. 

Arterial  hemorrhage  is  characterized  by  the  brighter  color  of 
the  blood  and  by  the  fact  that  it  escapes  in  a  distinct  remittent 
jet  of  considerable,  though  varying,  force.  The  jet  is  synchronous 
with  the  heart's  action,  increasing  during  ventricular  systole  and 
diminishing  during  ventricular  diastole. 

Means  to  Arrest  Hemorrhage.  The  Natural  Arrest  of 
Hemorrhage  is  effected  by  the  clotting  of  the  blood.  If  the  divided 
vessels  are  not  too  large  and  the  blood-pressure  not  too  great, 
nature  will  thus  be  able  to  bring  about  a  cessation  of  the  hemor- 
rhage. Nature  is  assisted  in  her  efforts  to  control  hemorrhage  from 
a  severed  artery  by  the  fact  that  when  an  artery  is  divided  its 
orifice  contracts,  thus  diminishing  the  size  of  the  opening  through 


Fig.  2.—  Esmarch  Bandage  and  Constrictor.     The  constrictor  is  provided 
with  a  chain  and  hook. 

which  the  blood  escapes,  and  further  by  the  fact  that  the  inner 
elastic  coat  of  the  vessel,  the  intima,  retracts,  coiling  up  within  the 
artery,  thus  blocking  the  lumen  of  the  vessel  and  offering  a  con- 
siderable impediment  to  the  flow. 

The  natural  arrest  of  hemorrhage  from  a  severed  vein  is  facili- 
tated by  the  low  blood-pressure  within  the  vessel  and  by  the  col- 
lapsibility  of  its  thin,  flaccid  wall. 

Artificial  Arrest  of  Hemorrhage. — Artificial  measures  are 
resorted  to,  as  a  rule,  to  control  hemorrhage.  These  may  be  classi- 
fied as  indirect  means,  acting  outside  at  a  distance  from  the  wound, 
and  direct  means,  acting  locally  within  the  wound. 

Indirect  Means.  The  Elastic  Bandage  and  Constrictor 
(Esmarch). — Operations  upon  the  extremities  may  be  rendered 
practically  bloodless  by  the  use  of  the  Esmarch  bandage  and  con- 
strictor. 


8  GENERAL  CONSIDERATIONS. 

The  extremity  being  elevated,  a  rubber  bandage  about  three 
inches  broad  is  applied  about  the  limb,  each  turn  being  drawn  pretty 
tight.  The  bandage  is  applied  spirally  about  the  limb,  commencing 
below  and  working  upward  toward  the  trunk,  each  turn  somewhat 
overlapping  its  predecessor;  in  this  way  the  blood  is  forced  out  of 
the  limb.  Having  reached  a  point  above  the  site  of  the  proposed 
operation,  a  rubber  band  or  thick  elastic  tube,  the  constrictor,  is 
passed  around  the  limb  several  times  and  then  made  fast.  The 
rubber  spiral  bandage  may  then  be  removed. 

In  most  cases  the  application  of  the  rubber  spiral  bandage  may 
be  dispensed  with,  it  being  sufficient  to  elevate  the  limb  to  a  per- 
pendicular position  for  a  few  minutes,  at  the  same  time  massaging 
or  stripping  it  from  the  periphery  toward  the  trunk,  in  order  to 
force  the  bulk  of  the  blood  out  of  it.  While  the  limb  is  thus 
elevated,  the  rubber  constrictor  bandage  or  tube  is  applied  about 
the  upper  part  of  the  limb. 

In  cases  of  tuberculous  disease,  malignant  disease,  and  sepsis 
one  should  certainly  omit  stripping  the  limb  or  applying  the  rubber 
spiral  bandage  on  account  of  the  likelihood  of  forcing  infectious 
elements  onward  into  the  healthy  tissues.  Under  these  circum- 
stances one  should  be  content  with  elevation  of  the  limb  for  a  few 
minutes  before  applying  the  constrictor. 

The  rubber  constrictor  that  is  placed  about  the  limb  may  be 
secured  with  a  band  of  gauze  which  is  placed  underneath  the  con- 
strictor so  that  after  the  first  loop  of  an  ordinary  knot  has  been 
taken  in  the  constrictor  the  gauze  bandage  may  be  tied  over  this 
to  secure  it  and  prevent  it  from  slipping;  the  second  and  final  loop 
is  then  taken  in  the  rubber  constrictor.  The  constrictor  shown  in 
the  illustration  is  provided  with  a  chain  and  hook. 

The  constrictor  should  be  applied  sufficiently  tight  to  shut  off 
the  arterial  current,  but  not  tight  enough  to  bruise  the  nerve-trunks 
against  the  underlying  bone.  The  constrictor  may  be  left  on  for 
two  or  three  hours  without  any  untoward  results. 

For  operations  upon  the  lower  extremity,  except  at  the  hip-joint, 
the  constrictor  is  placed  about  the  thigh,  just  above  the  knee-joint 
or  higher  up,  nearer  the  hip-joint.  For  disarticulation  at  the  hip- 
joint  the  constrictor  is  placed  about  the  limb  as  high  up,  near  the 
trunk,  as  possible,  and  it  is  then  prevented  from  slipping  down  by 
steel  pins,  or  skewers,  which  are  passed  through  the  soft  parts 
(Wyeth). 


HEMORRHAGE.  9 

For  operations  upon  the  upper  extremity,  except  at  the  shoulder- 
joint,  the  ligature  is  placed  about  the  arm,  just  above  the  elbow- 
joint  or  higher  up  nearer  the  shoulder-joint.  For  disarticulation 
at  the  shoulder-joint  the  constrictor  is  applied  as  high  up  as  pos- 
sible; it  may  be  passed  through  the  axilla  and  over  the  shoulder 
and  prevented  from  slipping  by  a  steel  pin,  or  skewer,  that  is  thrust 
through  the  soft  parts,  transfixing  the  upper  part  of  the  deltoid 
muscle  mass. 

The  main  arterial  and  venous  trunks,  if  they  have  been  divided 
during  the  course  of  the  operation,  may  be  secured  and  ligated  before 
the  constrictor  is  removed.  Any  additional  bleeding  branches  may 
be  secured  and  ligated  after  the  constrictor  has  been  removed. 

By  Digital  Compression  of  the  Main  Arterial  Trunk  at  a  Distance 
from  the  Site  of  the  Operation. — During  amputation  of  the  thigh 
the  common  femoral  artery,  as  it  emerges  from  under  Poupart's 
ligament,  may  be  compressed  against  the  underlying  pubic  bone. 

During  amputation  of  the  forearm  or  disarticulation  at  the 
elbow-joint  the  brachial  may  be  compressed  against  the  humerus, 
and  during  amputation  through  the  upper  arm  or  at  the  shoulder- 
joint  the  hemorrhage  may  be  controlled  by  digital  compression  of 
the  subclavian  artery  against  the  first  rib.  This  plan  is  rather 
untrustworthy. 

Preliminary  Ligation  in  Continuity. — This  is  a  very  satisfactory 
method  of  controlling  hemorrhage  in  certain  bloody  operations.  For 
example,  in  disarticulation  at  the  hip-joint  preliminary  ligation  of 
the  common  femoral  may  be  practiced,  the  vein  being  tied  at  the 
same  time  through  the  same  incision.  In  amputation  of  the  tongue 
one  or  both  Unguals  may  be  ligated  as  a  preliminary  step  to  the 
main  procedure.  In  extirpation  of  the  lower  jaw,  etc.,  preliminary 
ligation  of  the  external  carotid  may  be  practiced  with  great  advan- 
tage. 

Position. — Position  of  the  part  has  much  to  do  with  the  severity 
of  the  hemorrhage  during  an  operation.  Elevation  of  the  part  is 
often  sufficient,  of  itself,  to  check  capillary  and  venous  hemorrhage. 
The  volume  of  arterial  blood  sent  to  the  part  is  diminished  and  the 
return-flow  through  the  veins  is  facilitated.  These  factors,  together, 
serve  to  markedly  diminish  the  pressure  in  all  the  vessels  of  the 
elevated  part.  This  is  especially  true  of  the  limbs,  but  also  of  the 
pelvis  and  the  head.  With  the  pelvis  raised  as  in  the  Trendelenburg 
position,  the  hemorrhage  during  the  course  of  operations  upon  the 


10 


GENERAL  CONSIDERATIONS. 


pelvic  organs  is  much  diminished.  During  operations  upon  the  head 
and  face,  with  the  patient  in  the  semi-erect  position,  the  hemorrhage, 
especially  the  venous,  will  be  found  to  he  very  much  less  than  it 
would  he  wTith  the  patient  in  the  Eose  position,  with  the  head  hanging 
low  over  the  end  of  the  table. 

Direct  Means  of  Controlling  Hemorrhage  are  applied 
within  the  wound  itself,  and  these  may  be  divided  into  three  groups: 
Agents  that  act  locally  through  the  nervous  system;  chemical  agents 
that  act  directly  upon  the  escaping  blood,  causing  it  to  coagulate; 
and  mechanical  agents. 

-     Agents  that  Act  Locally  through  the  Nervous  System. — Application 
of  heat  or  cold,  usually  in  the  form  of  water,  hot  or  cold,  or  ice, 


Fig.  3. — Trendelenburg  Position. 


tends  to  diminish  and  check  hemorrhage.  If  hot  water  is  used  it 
should  be  as  hot  as  the  hand  can  bear,  about  120°  F.;  if  cold,  it  should 
be  quite  cold. 

Heat  and  cold  both  act  by  causing  the  small  arterioles  to  con- 
tract and  diminish  in  size.  Heat  causes  albumin  to  coagulate  so  that, 
when  heat  is  applied  to  a  wound,  the  wound  surface  becomes  glazed 
with  a  thin,  albuminous  film,  and  in  this  way  heat  possesses  an 
additional  potency  in  checking  oozing.  Heat  is  a  more  effective 
agent  in  controlling  hemorrhage  than  cold,  since  the  latter  acts  only 
by  causing  a  diminution  in  caliber  of  the  small  arteries. 

Heat  in  the  form  of  a  hot  saline  irrigation  is  a  very  satisfactory 
agent  to  check  oozing  from  capillaries  and  small  arteries  and  veins. 


HEMORRHAGE.  H 

Chemical  Agents.  Styptics. — These  agents  tend  to  check  hem- 
orrhage by  acting  directly  upon  the  escaping  blood,  causing  it  to 
coagulate,  and  thus  seal  the  mouths  of  the  severed  vessels.  They 
are  but  little  used  except  in  operations  upon  the  nose,  etc.,  and  are 
of  service  only  to  control  capillary  hemorrhage  and  oozing  from 
small  veins  and  arteries.  The  common  styptics  are  the  persulphate 
of  iron,  tincture  of  the  chloride  of  iron,  powdered  alum,  tannic  acid, 
extract  of  suprarenal  capsule,  etc. 

The  styptic  cotton  is  ordinary  absorbent  cotton  impregnated 
with  one  of  these  agents. 

Mechanical  Means.  Digital  Compression.  —  With  the  finger 
in  the  wound  hemorrhage  may  be  controlled  by  pressure  exerted 
directly  upon  a  severed  vessel,  thus  closing  it  until  it  can  be  secured 
with  an  artery  forceps.  In  operations  upon  the  neck,  for  example, 
a  large  vessel  may  be  divided  and  then  so  obscured  by  the  great 
volume  of  escaping  blood  that  it  cannot  be  located  and  secured  with 
the  artery  forceps.  With  the  finger  thrust  into  the  wound  the  hem- 
orrhage may  be  checked  temporarily  by  compressing  the  injured 
vessel  until  the  wound  can  be  cleared  of  blood  and  the  vessel  located 
and  grasped  with  an  artery  clamp.  This  is  especially  true  of  large 
veins;  when  cut,  the  blood  may  well  into  the  wound  in  such  volume 
that  one  is  unable  to  locate  the  divided  vessel. 

Digital  compression  may  be  applied  to  the  main  vessels  in  the 
wound  before  they  are  divided  in  order  to  minimize  the  loss  of 
blood.  For  example,  in  exarticulating  at  the  shoulder-joint,  after 
the  incisions  have  been  made,  but  before  the  brachial  artery  and 
adjoining  vessels  have  been  cut,  the  assistant  grasps  the  mass  of 
soft  parts  which  includes  the  main  vascular  trunks  and  compresses 
these  between  the  thumb  and  fingers  until  after  the  limb  has  been 
amputated  and  the  vessels  secured  by  the  operator. 

Tamponade. — This  is  really  one  way  of  applying  the  principle 
of  compression.  This  method  is  especially  serviceable  in  controlling 
oozing  and  bleeding  from  veins.  For  example,  hemorrhage  from  an 
injured  intracranial  sinus  may  be  readily  controlled  by  packing  a 
strand  of  gauze  into  the  wound  between  the  sinus  and  the  skull. 

If  a  wound  is  tamponed  and  a  good  snug  dressing  applied  so  as 
to  exert  a  considerable  degree  of  firm  compression,  this  will  usually 
suffice  to  check  all  oozing  from  capillaries  and  small  veins. 

Bleeding  from  the  nutrient  artery  of  a  bone  may  be  checked 
by  plugging  the  orifice  of  the  nutrient  canal  with  a  piece  of  catgut 


12  GENERAL  CONSIDERATIONS. 

or  a  wooden  peg.  Oozing  from  the  end  of  a  long  bone,  from  the 
edges  of  the  bones  of  the  skull  in  craniectomy,  etc.,  is  readily  con- 
trolled by  a  few  minutes'  firm  compression  with  a  hot  gauze  pad. 

Suture  of  the  Wound  controls  hemorrhage  from  capillaries  and 
small  veins  by  bringing  the  contiguous  surfaces  into  apposition,  and 
is  simply  one  method  of  applying  the  principle  of  compression. 

Forci pressure  consists  in  crushing  the  coats  of  the  severed  ves- 
sels with  haemostatic  forceps.  It  is  a  well-known  fact  that  even 
large  arteries  when  crushed  or  torn  do  not  bleed,  and  it  is  upon  this 
same  principle  that  forcipressure  is  applied  to  control  hemorrhage. 

The  bleeding  artery  or  vein  is  seized  with  the  forceps,  which  is 
then  closed  down  upon  the  vessel  with  much  force,  in  this  way 
crushing  the  coats  of  the  vessel,  especially  the  inner  coat  and  so 
effectually  controlling  the  hemorrhage.  If  the  vessels  are  small  the 
forceps  may  be  removed  after  a  few  minutes,  when  it  will  be  found 
that  the  hemorrhage  has  ceased.  Forcipressure  is  a  very  satisfactory 
method  of  dealing  with  larger  vessels  when  situated  deep  in  a  small 
wound  where  they  are  not  readily  accessible  for  ligation.  Under 
these  circumstances,  however,  it  is  wise  to  allow  the  forceps  to  re- 
main in  place  for  twenty-four  to  forty-eight  hours,  including  them 
in  the  dressing,  since  the  hemorrhage  might  recur  if  they  were 
removed  earlier.  By  allowing  the  forceps  to  remain  one  gives  the 
blood  a  chance  to  form  a  good  firm  clot  to  occlude  the  vessel. 

The  angiotribe,  a  bulky  crushing  instrument,  is  applied  upon 
this  principle.  It  is  provided  with  a  screw  which  enables  one  to 
apply  great  pressure  to  the  parts  within  the  grasp  of  its  blades. 
This  instrument  has  been  used  for  crushing  the  broad  ligament  in 
vaginal  hysterectomy,  but  has  not,  as  yet,  won  for  itself  a  place  in 
popular  favor. 

Torsion. — This  method  of  occluding  a  bleeding  vessel  consists 
in  seizing  the  end  and  twisting  it  until  the  inner  coat  of  the  vessel 
is  ruptured  and  the  end  of  the  vessel,  in  the  grasp  of  the  forceps, 
is  twisted  free.  This  measure  may  be  applied  to  small  arteries  and 
veins  as  an  adjunct  to  forcipressure.  Torsion  may  be  more  effect- 
ually applied  by  grasping  the  free  end  of  the  vessel  with  one  forceps 
and  the  vessel  itself  a  short  distance  beyond,  transversely,  with  a 
second  forceps.  While  the  vessel  is  steadied  with  the  forceps  that 
grasps  it  transversely,  it  is  twisted  repeatedly  upon  itself  with  the 
forceps  that  grasps  its  extremity. 

Ligature. — The  most  commonly  employed  and  safest  means  of 


HEMORRHAGE. 


13 


securing  severed  arteries  and  veins  especially  if  of  large  caliber.  In 
the  day  of  the  non-absorbable,  non-aseptic  ligature  many  plans  were 
devised  to  obviate  the  use  of  the  ligature,  since  it  had  to  be  cast 
off  before  the  wound  could  heal  and  thus  precluded  the  possibility 
of  union  by  first  intention,  and  because,  as  the  ligature  separated 
and  came  away,  it  was  often  accompanied  by  a  dangerous  secondary 
hemorrhage. 

With  the  aseptic,  absorbable  ligature,  an  ideal  method  of  con- 
trolling hemorrhage  in  the  wound  was  instituted.  The  aseptic,  ab- 
sorbable ligature  permits  the  immediate  closure  of  the  wound  and 
does  not  in  any  way  interfere  with  the  healing  process.     Some  sur- 


Fig.  4.— Square  Knot. 


Fig.  5.— Slip-knot. 


Fig.  6.— Surgeons'  Knot.    The  first  loop  is  made  double  to  prevent  slipping 
while  taking  the  second  loop. 


geons  still  use  silk  for  ligature.  Although  silk  may  be  rendered 
absolutely  aseptic,  it  has  the  disadvantage  of  not  being  absorbable, 
and  may  therefore  occasionally  act  as  a  foreign  body,  keeping  the 
wound  open  until  it  separates  or  until  it  is  removed.  The  ligatures 
may  be  applied  in  the  wound  before  the  vessels  have  been  divided 
or  afterward,  and  may  be  applied  to  the  isolated  vessels  or  may  in- 
clude the  immediately  adjoining  soft  parts  as  well. 

Ligature  of  blood-vessels  before  they  have  been  severed  is  ex- 
emplified in  the  tying  of  the  external  jugular  in  operations  upon 
the  neck  after  the  vessel  has  been  exposed  in  the  incision,  but  before 
it  is  cut;   the  ligature  is  applied  double  and  the  vessel  then  divided 


14  GENERAL  CONSIDERxVTIONS. 

between  these.  Again,  in  disarticulation  through  the  hip-joint  the 
main  vessels  may  be  exposed  during  the  course  of  the  operation, 
ligated,  and  then  divided.  In  resecting  portions  of  the  alimentary 
canal  the  mesentery  or  omentum  that  carries  the  blood-supply  to 
the  parts  must  be  tied  off.  This  is  usually  done  in  sections,  each 
ligature  including  from  one  to  one  and  a  half  inches  of  the  mesen- 
tery or  omentum;  in  this  case  not  only  are  the  blood-vessels  in- 
cluded in  the  ligatures,  but  all  of  the  tissue  from  one  ligature  to 
the  next. 

Ordinarily  the  ligatures  are  applied  to  the  vessels  after  they 
have  been  severed.  The  bleeding  point  is  seized  with  a  haemostatic 
forceps  and  the  ligature  is  then  slipped  over  the  end  of  this  and 
tied. 

Occasionally,  vessels  in  dense  fibrous  tissue,  in  the  dura  mater 
and  wall  of  the  chest,  when  cut,  retract  into  the  surrounding  tissue 
so  that  their  ends  cannot  be  seized  with  the  forceps.  Under  these 
circumstances  it  may  be  necessary  to  carry  the  ligature  around  the 
vessel  with  a  curved  needle. 

SUTURE  OF  THE  TISSUES. 

The  various  suture  materials  may  be  grouped  in  two  classes: 
temporary  and  permanent. 

Temporary  sutures  are  made  of  simple  catgut,  which  softens 
and  becomes  absorbed  in  from  five  to  ten  days  according  to  its  thick- 
ness, and  chromicized  catgut,  which  remains  longer,  from  two  to 
four  weeks  or  even  six  weeks,  according  to  its  thickness  and  the 
manner  of  its  preparation. 

Permanent  sutures  consist  of  silk,  silk-worm  gut,  kangaroo  ten- 
don, horse-hair  and  metal,  silver  wire,  etc.  (Kangaroo  tendon  be- 
comes absorbed  after  sixty  days;  so  that  it  is  not,  in  the  strict  sense, 
permanent.) 

Suture  of  the  Skin. — For  this  purpose  one  may  use  a  penetrating 
stitch,  continuous  or  interrupted,  or  a  non-penetrating  intracuticular 
stitch,  which  is  at  present  much  in  favor. 

The  stitch  should  not  be  drawn  too  tight,  as  it  constricts  the 
parts,  and  this  interferes  directly  with  the  blood-supply  and  the 
healing  process.  If  the  stitch  is  drawn  too  tight  it  may  cut  its  way 
through  the  tissues,  and  besides  may  add  much  to  the  pain  and 
discomfort  of  the  patient.     The  stitch  should  be  drawn  just  tight 


SUTURE  OF  THE  TISSUES. 


15 


enough  to  bring  the  parts  into  immediate  contact.  The  knots  should 
be  so  arranged  that  they  lie  to  one  side  or  the  other  of  the  wound. 

The  Inteacuticulae  Sutuee.  —  For  this  suture  simple  or 
chromicized  catgut  or  some  permanent  material — silk-worm  gut,  silk, 
etc. — may  be  used.  It  may  be  introduced  with  a  straight  needle  or 
with  a  curved  needle  in  a  holder. 

In  introducing  this  stitch,  one  should,  with  the  needle,  catch 
the  firm  under  layer  of  the  skin  proper,  avoiding  the  loose,  sub- 
cutaneous fat  and  connective  tissue,  and  with  each  puncture  of  the 
needle  take  a  good  long  bite;   after  crossing  from  one  edge  of  the 


Fig.  7. — Intracuticular  Suture.     A,  end  of  suture  fixed  with  a  pledget  of  gauze. 


incision  to  the  other  one  should  take  care  to  enter  the  needle  directly 
opposite  the  point  at  which  it  emerged  or  even  a  trifle  back  of  this. 
The  suture  may  be  secured  at  each  end  with  a  small  pledget  of  gauze. 
One  pad  is  fixed  to  the  end  of  the  thread  before  commencing  the 
suture,  and  then,  after  the  needle  emerges  through  the  last  puncture, 
it  is  carried  through  the  second  pad  and  the  suture  secured  with  one 
or  two  turns  about  this. 

Suture  of  Muscle. — Divided  muscle  is  usually  approximated  with 
absorbable  material,  simple  or  chromicized  catgut.  If  the  muscle 
has  been  cut  across,  at  right  angles  to  the  course  of  its  fibers,  the 


16  GENERAL  CONSIDERATIONS. 

part  should  be  placed  in  a  position  to  relax  the  muscle  and  special 
care  should  be  exercised  to  bring  the  cut  edges  securely  together. 
This  is  accomplished  by  introducing  a  sufficient  number  of  inter- 
rupted sutures  or  a  continuous  suture  of  moderately  thick  catgut, 
each  taking  a  good  secure  bite  in  the  muscle,  or  one  may  use  several 
mattress  sutures  for  this  purpose.  If  the  muscle  has  been  divided 
along  the  course  of  its  fibers, — i.e.,  between  its  fibers, — several  in- 
terrupted catgut  sutures  will  usually  suffice  to  retain  its  edges  in 
apposition. 

If  the  sheath  of  a  broad  muscle  has  been  divided, — for  exam- 
ple, the  sheath  of  the  rectus, — care  should  be  taken  to  unite  accu- 
rately, with  catgut,  simple  or  chromicized,  the  edges  of  the  sheath. 

In  operations  for  the  cure  of  hernias  the  edges  of  the  muscles 
are  sometimes  joined  with  a  non-absorbable  suture  material, — silk, 
silk-worm  gut,  or  silver  wire, — with  the  idea  of  leaving  these  as 
permanent  sutures  to  retain  the  parts  in  close  apposition. 


Fig.  8.— Bone  Drill  with  Eye  near  the  Point  to  carry  Suture,  etc. 

Suture  of  Tendons. — Severed  tendons  are  sewed  end  to  end  with 
some  absorbable  suture  material.  A  single  mattress  suture  or  one 
or  more  ordinary  interrupted  sutures  that  pass  through  the  tendon 
proper  are  usually  employed  for  this  purpose  (see  Fig.  236).  If  a 
part  of  the  tendon  has  been  destroyed  so  that  the  ends  cannot  be 
approximated,  a  flap  may  be  turned  back  from  one  or  both  ends  in 
order  to  meet  this  deficiency. 

Suture  of  Nerves. — The  ends  of  a  divided  nerve  may  be  joined 
with  one  or  two  catgut  sutures  which  secure  the  sheath  of  the  nerve, 
or,  better,  these  sutures  may  penetrate  the  nerve  proper. 

Bone  and  Cartilage. — For  the  purpose  of  suturing  bone  and 
cartilage  silver  wire  is  usually  employed.  Sometimes  heavy,  chro- 
micized catgut  is  used.  In  order  to  pass  the  sutures,  holes  must 
first  be  made  through  the  bone.  This  is  done  with  the  drill.  Before 
withdrawing  the  drill  the  suture  is  introduced  through  the  small 
eye  in  the  point  of  the  drill,  and  then  as  the  instrument  is  with- 
drawn it  brings  the  suture  after  it.     If  the  suture  is  too  thick  to 


SUTURE  OF  THE  TISSUES. 


17 


enter  the  eye  in  the  point  of  the  drill,  one  may  pass  a  loop  of  silk 
through  the  eye  of  the  drill  and  with  this  draw  the  suture  through. 

Bones  are  sometimes  joined  with  one  or  more  sutures  of  chro- 
micized  catgut  which  do  not  go  through  the  bone,  hut  include  the 
periosteum  and  the  fibrous  tissue  that  cover  the  bone;  this  method 
may  be  used,  for  example,  to  unite  a  fractured  patella  so  as  to  avoid 
entering  the  knee-joint  and  the  handling  that  would  be  necessary 
in  the  making  of  drill-holes. 

Bones  may  also  be  joined  by  steel  nails,  ivory  pegs,  etc.,  that 
are  driven  from  one  fragment  of  bone  into  the  other. 


Fig.  9.— Segment  of  Bowel.    Interrupted 
Lembert  sutures  in  place. 


Pig.  10.— Segment  of  Bowel.  Lembert 
sutures  tied.  It  will  be  noted  that  they 
do  not  penetrate  through  the  entire 
thickness  of  the  wall  of  the  gut. 


Suture  of  Serous  Surfaces,  Bowel,  etc. — The  essential  object  is 
to  secure  rapid  adhesion  by  approximating  serous  surface  to  serous 
surface,  and  this  is  accomplished  by  means  of  the  Lembert  suture. 

The  Lembert  suture  catches  the  serous  and  muscular  coats  of 
the  bowel,  but  does  not  penetrate  into  the  mucous  membrane  layer. 
It  should  not  enter  into  the  cavity  of  the  gut,  etc.  For  this  suture 
silk  should  be  employed.  It  may  be  introduced  interrupted  or  con- 
tinuous, and  is  applied  in  such  a  manner  as  to  invert  the  edges  and 
join  opposite  serous  surfaces. 

A  straight  round  cambric  needle  is  usually  employed  to  carry 
the  Lembert  suture,  but  occasionally,  especially  in  sewing  deep 
within  the  abdominal  cavity,  a  thin  curved  surgeon's  needle  in  a 
holder  may  be  more  convenient. 


18 


GENERAL  CONSIDERATIONS. 


In  applying  the  Lembert  suture  the  needle  is  introduced  a  short 
distance  from  the  edge  of  the  wound,  and  after  passing  through  the 
wall  of  the  gut,  catching  up  the  serous  and  muscular  coats,  but  not 
entering  the  mucous  membrane  coat,  it  emerges  near  the  edge  of 
the  incision;  the  needle  is  then  carried  across  the  incision  and  in- 
troduced upon  the  opposite  side  at  a  point  directly  opposite  and  in 
a  similar  manner. 

The  suture  may  also  be  introduced  and  carried  in  the  wall  of 
the  gut  along  a  line  parallel  with  the  incision  instead  of  at  right 
angles  to  the  line  of  the  incision. 


Fig.  12.— Halsted's  Intestinal  Suture. 


Fig.  11. — dishing  Suture  Applied  to 
Close  Opening  in  the  Bowel.  It  is  a  con- 
tinuous stitch  and  passes  through  the  wall 
of  the  gut  parallel  with  the  line  of  the  in- 
cision instead  of  at  right  angles  to  it. 


Small  wounds  of  the  bowel  may  be  closed  with  a  single  row  of 
Lembert  sutures.  Larger  wounds  of  the  hollow  abdominal  viscera 
should  be  closed,  first,  with  a  continuous  or  interrupted  row  of  silk 
or  catgut  sutures  that  penetrate  through  all  the  layers  of  the  organ, 
joining  the  parts  accurately  edge  to  edge,  and  then,  after  the  open- 
ing has  been  thus  closed,  the  Lembert  stitch,  which  unites  the 
opposite  serous  surfaces  to  each  other,  is  applied.  The  Lembert 
stitch  buries  the  penetrating  suture  and  inverts  the  edges  of  the 
wound,  so  that  the  serous  surfaces  become  apposed  to  each  other. 
The  outside  Lembert  suture  that  buries  the  deeper  penetrating 
mucous  suture  is  sometimes  called  the  "outside  serous"  suture. 


SUTURE  OF  THE  TISSUES.  19 

Suture  of  Wounds  of  the  Bladder. — Closure  of  wounds  of 
the  urinary  bladder  requires  special  mention.  They  may  involve 
the  serous  or  the  non-serous  portion  of  the  organ. 

Wounds  of  the  serous  portion  should  be  first  closed  with  a 
continuous  catgut  stitch,  which  should  include  all  the  coats  except 
the  mucous  membrane.  Each  loop  of  this  suture  should  be  drawn 
tight.  This  serves  to  close  the  opening.  A  continuous  Lembert 
stitch  of  silk  is  then  introduced  which  unites  the  opposite  serous 
surfaces,  immediately  adjacent  to  the  edges  of  the  incision,  to  each 
other  and  buries  the  first  row  of  sutures. 

Wounds  of  the  non-serous  portion  of  the  bladder:  i.e.,  its  ante- 
rior wall.  Wounds  of  this  part  of  the  bladder  should  be  closed  with 
a  continuous  or  interrupted  row  of  catgut  sutures  that  include  the 
whole  thickness  of  the  bladder  wall  except  its  mucous  membrane. 
These  sutures  should  close  the  opening  in  the  wall  of  the  bladder 
very  accurately;  owing  to  the  absence  of  the  serous  coat  from  this 
part  of  the  bladder,  the  Lembert  suture — "outside  serous  suture" — 
cannot  be  applied.  Since  we  cannot  look  for  rapid  adhesion  in  wounds 
of  this  part  of  the  bladder,  it  is  well  to  allow  the  abdominal  incision 
to  remain  open,  packing  with  gauze  down  to  the  suture  line  in  the 
wall  of  the  bladder,  so  that,  if  there  is  any  leakage,  the  fluid  may 
find  its  way  out  of  the  wound. 


PART  II. 

HEAD    AND    FACE. 


HEAD. 


Surgical  Anatomy  of  the  Head.  The  Scalp. — The  head  is  cov- 
ered by  the  scalp,  which  is  a  dense  layer,  composed  of  the  skin, 
subcutaneous  connective  tissue,  and  the  aponeurosis  of  the  occipito- 
frontalis  muscle.    These  three  layers  together  constitute  the  scalp. 

The  subcutaneous  connective  tissue  is  dense  and  serves  to  unite 
the  skin  intimately  with  the  underlying  aponeurosis  of  the  occipito- 
frontalis  muscle.  It  is  continuous  behind,  in  front,  and  upon  the 
sides  with  the  superficial  fascia  (subcutaneous  fatty  and  connective 
tissue  layer)  of  these  parts.  In  it  ramify  the  blood-vessels  and 
nerves. 

The  arteries  of  the  scalp  are  large  and  numerous.  Bleeding 
from  these  vessels  can  often  be  controlled  by  pressure  applied  against 
the  underlying  bony  surface.  Anteriorly  are  the  frontal  and  supra- 
orbital arteries;  on  the  sides,  branches  of  the  temporal;  and,  behind, 
the  occipital  and  posterior  auricular.  These  vessels  all  course  from 
below  upward  toward  the  crown  of  the  head,  their  branches  anas- 
tomosing freely  with  each  other  all  around.  These  arteries  are 
found  at  times  to  be  very  tortuous. 

The  occipito-frontalis  muscle  is  broad  and  flat,  consisting  of 
an  anterior  and  a  posterior  muscular  portion  and  an  intermediate 
aponeurotic  portion  which  covers  the  top  of  the  skull.  This  apo- 
neurosis is  firmly  united  with  the  overlying  skin,  whereas  it  is  but 
loosely  attached  to  the  pericranium  beneath.  Upon  either  side  the 
aponeurosis  is  continued  into  the  temporal  fascia.  In  cases  where 
the  scalp  is  torn  off,  the  aponeurosis  of  the  occipito-frontalis  comes 
away  with  the  skin  and  subcutaneous  connective  tissue,  thus  leaving 
the  pericranium  exposed. 

In  the  temporal  region  the  subcutaneous  connective  tissue  layer 
is  looser  than  upon  the  top  of  the  head,  and  in  it  run  the  branches 
of  the  temporal  artery  and  vein  and  the  auriculo-temporal  nerve. 
Beneath  the  subcutaneous  layer  in  the  temporal  region  is  the  tem- 
poral fascia.    This  is  a  strong,  fibrous  layer  covering  in  the  temporal 

(20) 


SURGICAL  ANATOMY  OF  THE  HEAD.  21 

muscle,  and  ia  attached  above,  all  around,  to  the  temporal  ridge, 
and,  below,  to  the  upper  border  of  the  zygomatic  arch,  where  it  splits 
into  two  layers,  between  which  are  included  a  small  arterial  and 
nervous  branch.  The  aponeurosis  of  the  occipito-frontalis  muscle 
thins  out  upon  each  side  and  is  continued  into  this  temporal  fascia. 
Beneath  the  temporal  fascia  is  the  temporal  muscle.  This  is  a  broad, 
fan-shaped  muscle  which  arises  from  the  whole  surface  of  the  tem- 
poral fossa  and  from  the  under  surface  of  the  temporal  fascia;  it  is 
attached  by  a  strong  tendon  to  the  tip,  anterior  border,  and  inner 
surface  of  the  coracoid  process  of  the  inferior  maxilla. 

The  pericranium  is  a  shining,  fibrous  layer  of  periosteum  which 
is  closely  attached  to  the  external  surface  of  the  bones  of  the  skull: 
most  intimately  at  the  suture  lines,  through  which  it  is  continuous 
with  the  dura  mater  lining  the  inner  surface  of  the  bones. 

Collections  of  pus  or  blood  between  the  skin  and  the  occipito- 
frontalis  aponeurosis  give  rise  to  circumscribed  tumors  because  they 
cannot  become  diffused  in  the  dense  subcutaneous  connective  tissue 
layer.  Between  the  aponeurosis  and  the  pericranium,  however,  such 
collections  may  become  widely  diffused,  owing  to  the  looseness  of  the 
tissue  which  joins  the  aponeurosis  and  the  pericranium  together, 
and,  raising  the  whole  scalp  so  that  it  resembles  a  water-bag,  may 
gravitate  and  point  in  the  frontal  or  occipital  regions.  Beneath  the 
pericranium,  between  this  layer  and  the  surface  of  the  bone,  such 
collections  are  again  limited,  owing  to  the  close  union  between  this 
structure  and  the  underlying  bone. 

The  Skull  is  a  rounded,  elastic  case  made  up  of  a  number  of 
bones  joined,  for  the  most  part,  edge  to  edge.  The  base  of  the 
skull  is  irregular  and  is  strengthened  along  certain  lines  by  ribs  of 
bone,  the  intervening  portions  being  often  very  thin.  It  presents 
many  openings  for  the  entrance  and  exit  of  important  structures. 
The  vault  of  the  skull  is  arched,  rounded,  and  smooth.  The  bones 
entering  into  the  formation  of  the  vault  are  flat  and  vary  in  thick- 
ness in  different  places.  These  so-called  flat  bones  that  enter  into 
the  formation  of  the  vault  are  made  up  of  spongy  tissue — diploe — 
inclosed  between  two  plates  of  hard  compact  bone:  the  inner  and 
outer  tables.  The  outer  table  is  twice  as  thick  as  the  inner.  The 
external  surface  of  the  skull  is  covered  by  the  periosteum  (peri- 
cranium) already  mentioned.  The  internal  surface  is  lined  by  the 
dura  mater,  which  is  very  closely  applied  to  the  surface  of  the  bones, 
serving  the  purpose  of  a  periosteum;    the  large  vascular  branches 


22  HEAD  AND  FACE. 

that  ramify  upon  the  inner  surface  of  the  skull  are  lodged  in  the 
dura. 

The  spongy  substance — diploe' — inclosed  between  the  two  layers 
of  compact  bone  presents  an  extensive  system  of  venous  canals. 
These  communicate  with  the  intracranial  venous  channels,  that  are 
found  between  the  layers  of  the  dura  mater,  and  with  the  veins  of 
the  scalp.  The  vault  of  the  skull  varies  in  thickness  in  different 
places  and  in  different  individuals.  About  the  middle  it  is  thin,  its 
average  thickness  in  this  situation  being  from  4  to  5  mm.;  it  be- 
comes thicker  toward  the  front  and  still  more  so  toward  the  occiput. 
Along  the  course  of  the  intracranial  venous  sinuses,  and  also  corre- 
sponding to  the  depressions  for  the  Pacchionian  bodies,  which  are 
located  upon  either  side  along  the  middle  line,  the  bone  is  thinner. 
Where  the  skull  is  thin  it  is  at  the  expense  of  the  diploe,  which  in 
certain  parts  may  be  entirely  absent,  the  two  tables  being  in  direct 
contact  with  each  other.  This  is  the  condition  in  the  temporal 
region. 

Corresponding  to  the  frontal  region  the  skull  is  marked  by  the 
presence  of  two  large  air-spaces,  one  on  either  side,  the  frontal 
sinuses;  these  are  separated  from  each  other  by  a  septum  located 
more  or  less  in  the  middle  line.  The  anterior  wall  of  these  spaces 
is  thick,  and  consists  of  two  layers  of  hard,  compact  bone  with  inter- 
vening diploe.  The  posterior  wall  is  thin.  The  frontal  sinuses  vary 
in  size  in  different  individuals,  are  lined  with  mucous  membrane, 
and  communicate  with  the  nasal  fossa  through  a  large  canal,  the 
infundibulum,  which  opens  under  the  middle  turbinated  bone, 
toward  the  front. 

In  the  mastoid  region  the  bone  is  prolonged  downward  in  the 
form  of  a  teat-like  process:   the  mastoid  process. 

Corresponding  to  the  temporal  region,  the  skull  is  made  up  of 
the  squamous  portion  of  the  temporal  bone,  which  is  very  thin,  and 
of  part  of  the  parietal  bone.  Ascending  upon  the  surface  of  the 
bone,  beneath  the  temporal  muscle,  are  several  deep  temporal  arte- 
rial branches. 

The  parietal  and  the  occipital  bones  and  the  mastoid  portion 
of  the  temporal  bone  present  openings  for  the  passage  of  veins  from 
the  exterior  of  the  skull  which  empty  into  the  intracranial  sinuses, 
and  these  may  be  the  routes  through  which  infection  is  carried  into 
the  cranial  cavity. 

The  Dura  Mater  is  a  strong,  non-elastic,  fibrous  membrane 


SURGICAL  ANATOMY  OF  THE  HEAD.  23 

which  lines  the  -inner  surface  of  the  skull  and  is  closely  attached 
to  the  bones  (periosteum),  hut  may  he  separated  without  much  force. 
It  supports  the  intracranial  arteries  and  veins  (venous  sinuses),  and 
when  separated  from  the  surface  of  the  hones  carries  these  vessels 
with  it.  Anteriorly,  ramifying  in  the  dura  mater,  is  the  anterior 
meningeal  artery,  which  is  a  branch  of  the  ethmoid.  Corresponding 
to  the  middle  fossa  of  the  skull  and  the  temporal  region,  the  middle 
meningeal  artery  is  found.  This  is  a  branch  of  considerable  size, 
and  is  of  much  surgical  importance;  it  is  derived  from  the  internal 
maxillary  and  enters  the  skull  through  the  foramen  spinosum  in  the 
base  of  the  skull.  Behind  are  the  posterior  meningeal  branches 
which  are  derived  from  the  occipital  and  the  vertebral. 

There  are  a  number  of  large  venous  sinuses  which  are  situated 
between  the  layers  of  the  dura  and  which  groove  the  surface  of  the 
bones  along  their  course.  The  largest  of  these  are  the  longitudinal, 
the  lateral,  and  the  cavernous. 

The  longitudinal  sinus  runs  from  before  backward  along  the 
line  of  the  sagittal  suture  from  the  foramen  caecum  in  front  to  the 
occipital  protuberance  behind. 

The  lateral  sinus  is  important  surgically.  From  the  center  of 
the  occipital  bone  that  of  either  side  passes  transversely  outward, 
grooving  the  internal  surface  of  the  occipital  bone  upon  a  line  cor- 
responding to  the  attachment  of  the  trapezius  and  sterno-mastoid 
muscles  and  the  inner  surface  of  the  posterior  inferior  corner  of  the 
parietal;  here  the  sinus  curves  downward,  grooving  the  inner  sur- 
face of  the  mastoid,  and  from  this  bone  is  continued  again  over  on 
to  the  occipital,  crossing  the  upper  surface  of  the  jugular  process 
of  this  bone,  to  join  with  the  inferior  petrosal  sinus  to  form  the 
internal  jugular  vein.  The  course  of  the  transverse  portion  of  the 
lateral  sinus  corresponds  to  a  line  drawn  from  the  external  occipital 
protuberance  to  the  upper  margin  of  the  external  auditory  meatus. 

The  cavernous  sinus  is  lodged  in  the  groove  upon  the  side  of 
the  body  of  the  sphenoid  bone.  The  internal  carotid  artery  passes 
from  behind  forward,  from  the  orifice  of  the  carotid  canal  in  the 
apex  of  the  petrous  portion  of  the  temporal  bone,  where  the  artery 
enters  the  cranium,  to  the  point  where  it  divides  into  its  terminal 
branches.  This  part  of  the  internal  carotid  artery  is  enveloped  by 
the  cavernous  sinus,  the  wall  of  the  sinus  being,  as  it  were,  wrapped 
around  the  artery.  The  sixth  nerve  is  also  inclosed  entirely  within 
the  sinus,  lying  below  and  to  the  outer  side  of  the  artery.    The  third, 


24  HEAD  AND  FACE. 

fourth,  and  the  ophthalmic  division  of  the  fifth  nerve  are  located 
in  the  outer  wall  of  the  cavernous  sinus,  but  are  not  contained  within 
its  lumen  as  are  the  internal  carotid  artery  and  the  sixth  nerve. 

The  blood-pressure  within  these  sinuses  is  low,  and  hemorrhage 
is  readily  controlled  by  packing  with  gauze. 

The  Pia  Mater. — The  skull  contains  the  brain  inclosed  within 
its  own  peculiar  membrane:  the  pia  mater.  This  is  a  connective 
tissue  membrane  which  serves  to  support  the  vessels  which  supply 
the  brain,  and  contains  within  its  meshes  the  cerebro-spinal  fluid. 
The  pia  mater  is  not  a  simple  flat  membrane,  but  is  really  made  up 
of  two  layers  joined  together  by  septa  which  divide  it  up  into  a 
mesh-work  of  cellular  spaces  within  which  is  contained  the  cerebro- 
spinal fluid.  It  has  been  compared  to  a  water-soaked  connective 
tissue.  It  has  no  connection  with  the  dura  mater;  so  that  between 
the  inner  surface  of  the  dura  and  the  external  surface  of  the  pia 
there  is  a  narrow  free  space,  or  crevice,  which  contains  a  minute 
quantity  of  fluid.     This  is  called  the  subdural  space. 

Between  the  layers  of  the  pia  mater  there  is  a  great  system 
of  spaces  communicating  with  each  other,  and  this  is  sometimes 
called  the  subarachnoid  space;  as  already  stated,  the  cerebro-spinal 
fluid  is  contained  in  this  space.  This  membrane,  the  pia  mater,  is 
attached  by  its  deep  internal  surface  directly  to  the  surface  of  the 
brain,  dipping  down  between  its  convolutions  and  lobes.  It  acts 
like  a  water  cushion,  preserving  the  blood-vessels  from  pressure,  and 
also  permits  intracranial  tumors,  etc.,  to  acquire  an  appreciable 
thickness  before  they  begin  to  cause  pressure  symptoms. 

OPERATIONS  UPON  THE  HEAD. 

Trephining. — By  trephining  we  mean  making  an  opening  into, 
or  resecting  a  portion  of,  the  skull.  This  operation  is  done  to  relieve 
compression  either  from  depressed  bone  or  from  extravasated  blood, 
and  to  treat  intracranial  conditions,  as  abscess,  tumor,  etc. 

The  patient  is  placed  upon  the  back  with  a  thin  sand  bag  under 
the  head.  The  opening  in  the  skull  may  be  made  with  a  trephine, 
chisel,  or  rongeur  or  Keen  or  De  Vilbiss  forceps,  or  with  a  circular  saw 
or  a  rotary  drill. 

Trephining  for  Depressed  Fracture  of  the  Skull. — If  a 
wound  is  already  present,  this  should  be  utilized,  and,  if  necessary, 
may  be  enlarged  in  order  to  expose  the  site  of  fracture.    If  no  wound 


OPERATIONS  UPON  THE  HEAD.  25 

is  present  and  the  incision  is  a  matter  of  choice,  a  crescentic  or 
crucial  incision  may  be  employed,  or  a  U-shaped  flap  be  reflected. 
In  marking  out  this  flap  the  base  should  be  below,  toward  the  pe- 
riphery, so  as  to  insure  good  blood-supply  to  the  flap.  The  incision 
should  reach  through  the  periosteum  down  to  the  surface  of  the 
bone,  and  in  reflecting  the  flap  the  periosteum  should  be  included. 

After  the  site  of  the  fracture  has  been  exposed  and  spurting 
vessels  clamped  and  tied,  one  may  proceed  to  relieve  the  compression 
by  elevating  depressed  bone,  clearing  out  blood-clot,  etc.  A  num- 
ber of  loose  pieces  of  bone,  entirely  detached  from  the  periosteum 
(pericranium  and  dura  mater),  may  be  found,  and  these  may  be 
removed  with  a  thumb  forceps.  We  may  find  other  fragments  loose, 
but  still  attached,  at  least  in  part,  to  the  periosteum  or  dura  mater. 
These  may,  in  some  cases,  be  readily  elevated.  "We  may  find  other 
depressed  fragments  so  firmly  impacted,  wedged,  that  they  cannot 
be  elevated,  and  in  order  to  get  at  these  fragments  it  may  be  neces- 
sary to  remove  a  portion  of  the  adjoining  margin  of  bone,  either 
with  the  trephine  or  chisel.  If  the  trephine  is  used  for  this  purpose 
the  periosteum  is  scraped  back,  laying  bare  the  surface  of  the  bone 
which  is  to  be  removed.  When  the  trephine  is  first  applied  the 
center  pin  should  be  lowered  beyond  the  level  of  the  cutting  edge 
of  the  crown  of  the  trephine,  so  as  to  engage  in  the  bone  and  steady 
the  trephine  until  the  crown  has  cut  a  groove  within  which  it  may 
work  without  slipping,  when  the  pin  may  be  again  raised.  The 
trephine  should  be  so  placed  that  its  crown  will  partly  overlap  the 
edge  of  the  bone,  so  that  only  one-half  of  a  button  will  be  removed 
from  the  margin  adjoining  the  impacted  fragment.  The  trephine 
should  be  worked  with  a  firm,  steady  wrist  movement,  and  the  groove 
occasionally  probed  to  ascertain  if  the  bone  is  cut  through  at  any 
point.  The  use  of  such  force  as  would  result  in  sudden,  abrupt 
penetration  of  the  skull  should  be  avoided.  The  button  may  be 
loosened  by  gently  prying  with  the  elevator.  Bleeding  from  the 
edge  of  the  bone  ceases  after  a  few  moments'  pressure  with  a  hot 
gauze  pad. 

In  many  cases  the  liberation  of  an  impacted  fragment  is  best 
accomplished  by  using  the  chisel  to  cut  away  the  margin  of  the 
bone  that  holds  it  fast;  often,  with  a  few  strokes  of  the  mallet,  the 
fragment  is  freed  or  a  space  is  made  to  allow  the  use  of  the  elevator. 

Having  removed  all  loose  fragments  and  elevated  those  which 
are  still  attached  to  the  pericranium  and  dura  mater  and  rounded  off 


26  HEAD  AND  FACE. 

the  edges  of  any  defect  left  in  the  skull,  one  should  search  carefully 
for  any  loose  fragments  or  spiculae  which  may  be  concealed  under 
the  edge  of  the  opening  in  the  bone.  The  finger  or  probe  should 
be  used  for  this  purpose.  Small  pieces  may  be  washed  out  by  irri- 
gation with  a  weak  bichloride  solution  or  they  may  be  picked  out 
with  a  forceps.  One  should  examine  carefully  as  to  the  condition 
of  the  internal  table,  as  this  is  often  more  extensively  fractured 
than  is  indicated  by  the  appearance  of  the  external  table.  The 
internal  table  is  at  times  extensively  fractured  and  depressed  when 
the  corresponding  part  of  the  external  table  is  apparently  uninjured. 
Extravasated  clotted  blood,  between  the  dura  and  the  inner  surface 
of  the  bone,  or  beneath  the  dura,  between  it  and  the  pia  mater, 
should  be  removed  with  a  scoop  and  by  irrigation  and  any  severed 
vessels  tied  with  fine  catgut.  If  the  dura  mater  has  been  torn  the 
edges  of  the  opening  may  be  brought  together  with  a  fine  catgut 
suture. 

The  wound  in  the  scalp  may  be  closed  without  drainage  unless 
the  parts  have  been  exposed  to  the  chance  of  infection.  In  this  case, 
for  the  purpose  of  drainage,  a  narrow  strip  of  gauze  may  be  intro- 
duced through  one  corner  of  the  wound  and  reaching  down  to  the 
dura  mater. 

Trephining  for  Intracranial  Hemorrhage  (Middle  Men- 
ingeal). —  The  middle  meningeal  artery  is  the  usual  source  of 
traumatic  intracranial  hemorrhage. 

The  middle  meningeal  is  a  vessel  of  considerable  size,  and  is 
given  off  from  the  upper  aspect  of  the  first  part  of  the  internal 
maxillary  a  short  distance  beyond  its  origin  from  the  external 
carotid,  as  it  (the  internal  maxillary)  lies  beneath  the  neck  of  the 
condyle  of  the  jaw,  between  it  and  the  internal  lateral  ligament. 
The  middle  meningeal  passes  directly  upward  between  the  two  roots 
of  the  auriculo-temporal  nerve,  which  surround  the  commencement 
of  the  artery,  toward  the  base  of  the  skull,  and  enters  the  skull 
through  the  foramen  spinosum.  This  part  of  the  middle  meningeal 
artery  is  concealed  beneath  the  external  pterygoid  muscle,  the  ten- 
don of  which  is  attached  to  the  front  of  the  neck  of  the  condyle 
of  the  jaw.  In  front  and  internal  to  this  part  of  the  artery  is  the 
inferior  maxillary  division  of  the  fifth  nerve  and  its  motor  root,  these 
nerve  branches  emerging  from  the  skull  through  the  foramen  ovale. 

After  entering  the  skull  the  middle  meningeal  runs  a  short 
distance  outward  in  a  groove  in  the  floor  of  the  middle  fossa  and 


OPERATIONS  UPON  THE  HEAD.  27 

then  divides  into  two  branches.  The  anterior,  the  larger  branch, 
passes  forward  and  outward  across  the  floor  of  the  middle  fossa  of 
the  skull  and  across  the  anterior  inferior  angle  of  the  parietal  bone 
just  behind  the  outer  extremity  of  the  lesser  wing  of  the  sphenoid, 
and  may  be  exposed  as  it  ascends  upon  the  side  of  the  skull  at  a 
point  which  corresponds  to  the  intersection  of  two  lines  (Vogt), 
one  vertical,  a  thumb's  breadth  behind  the  external  angular  process, 
and,  the  other,  horizontal,  placed  two  fingers'  breadth  above  the 
zygoma.  The  posterior  branch  of  the  middle  meningeal  passes  out- 
ward across  the  squamous  portion  of  the  temporal  bone  and  then 
ascends  upward  and  backward  upon  the  inner  surface  of  the  poste- 
rior inferior  portion  of  the  parietal  bone  above  and  in  front  of  the 
groove  seen  here  for  the  lateral  sinus.  The  posterior  branch  may 
be  exposed  by  removing  a  button  of  bone  whose  center  is  one  inch 
above  and  one-half  inch  behind  the  external  auditory  meatus. 

The  middle  meningeal  and  its  branches  ramify  in  the  dura  and 
groove  the  surface  of  the  bones  against  which  they  are  applied.    The 


Fig.  13.— Hartley  Chisel.     This  chisel  is  pointed,  V  shape  en  section,  and  is 
very  convenient  for  cutting  the  groove  in  the  bone. 

anterior  branch,  as  it  approaches  the  anterior  inferior  angle  of  the 
parietal  bone,  is  lodged  in  a  deep  groove,  which  is  occasionally  con- 
verted into  a  complete  bony  canal. 

Temporary  Resection  of  the  Skull.  —  When  the  skull  is  intact, 
it  is  preferable,  in  order  to  gain  access  to  the  cranial  cavity,  to  do 
a  temporary  resection  of  the  skull  (Wagner),  turning  back  a  flap, 
which  consists  of  the  soft  parts,  periosteum,  and  corresponding 
piece  of  bone,  rather  than  to  remove  a  button  of  bone,  which  leaves 
a  permanent  defect  in  the  skull.  To  reach  the  middle  meningeal 
artery  or  its  divisions  this  is  a  most  satisfactory  method. 

A  horseshoe-shaped  flap  is  marked  out  in  the  temporal  region, 
with  its  arch  above  and  its  base  below  at  the  zygoma,  the  anterior 
leg  being  placed  a  good  finger's  breadth  behind  the  external  angular 
process  and  the  posterior  leg  just  in  front  of  the  tragus.  The  in- 
cision should  reach  through  the  soft  parts,  including  the  periosteum, 
down  to  the  bone.  The  flap  thus  marked  out  should  measure  in  its 
vertical  diameter  about  three  inches,  and  about  two  and  one-half 


28 


HEAD  AND  FACE. 


inches  across  its  widest  part.  At  its  base  the  flap  should  be  from 
one  and  one-half  to  two  inches  wide. 

The  temporal  artery  and  some  of  its  branches  are  usually 
divided,  and  must  be  clamped  and  tied. 

Eetracting  the  soft  parts,  but  without  separating  them  from 
the  surface  of  the  bone,  a  groove  is  cut  in  the  bone  all  around  corre- 


Fig.  14.— Temporary  Resection  of  the  Skull.  Osteo-tegumentary  flap 
turned  down,  exposing  dura.  MA,  anterior  branch  of  middle  meningeal  ar- 
tery.    MP,  posterior  branch  of  middle  meningeal  artery. 


spending  to  the  course  of  the  skin  incision.  This  may  be  accom- 
plished with  a  chisel,  or  one  may  commence  by  marking  out  the 
opening  with  a  revolving  saw  and  complete  it  with  the  chisel,  or  a 
small  opening  may  be  made  in  the  skull  with  a  trephine,  and  a  rotary 
drill  or  the  De  Vilbiss  bone-forceps  may  be  then  employed.  The 
line  of  section  through  the  bone  may  be  somewhat  oblique  so  that 
the  detached  piece  will  have  a  beveled  edge  and  thus  make  a  better 
fit  when  replaced.     The  elevator  is  introduced  into  the  upper  part 


OPERATIONS  UPON  THE  HEAD.  29 

of  the  groove  and  the  piece  of  bone  pried  out,  breaking  it  below, 
through  its  base,  near  the  zygoma,  and  then  this  flap,  which  consists 
of  all  the  soft  parts  with  the  corresponding  segment  of  bone  attached, 
is  turned  down  over  the  zygoma,  leaving  a  considerable  opening  in 
the  skull  through  which  the  dura  mater  and  the  branches  of  the 
middle  meningeal  artery,  which  ramify  in  it,  are  exposed. 

If  the  opening  in  the  skull  is  not  sufficiently  large,  it  may  be 
further  enlarged  by  cutting  away  its  margins  with  the  bone  forceps. 

The  extravasated  blood  is  usually  located  between  the  dura  and 
the  bone,  so  that  as  soon  as  the  plate  of  bone  has  been  turned  back 
we  expose  the  blood,  which  is,  as  a  rule,  partly  clotted.  This  may 
be  cleared  out  with  a  scoop  and  irrigation,  after  which  the  ends  of 
the  divided  vessel  are  sought  and  tied.  Ordinarily  they  may  be 
seized  with  a  clamp  and  ligated  in  the  usual  manner;  there  may, 
however,  be  some  difficulty  in  securing  the  ends  of  the  divided  ves- 
sel, as  they  may  have  retracted  within  the  canal  in  the  dura  in  which 
they  are  situated  to  such  an  extent  that  they  cannot  be  readily  seized 
with  the  artery  forceps,  and  it  may  then  be  necessary  to  carry  a 
ligature  around  the  vessel  with  a  curved  needle. 

Should  the  blood  have  collected  beneath  the  dura  mater,  be- 
tween it  and  the  surface  of  the  brain  (pia  mater),  in  the  subdural 
space,  it  would  be  necessary  to  make  an  opening  in  the  dura  in  order 
to  clear  the  blood  out. 

Usually  the  anterior  branch  of  the  middle  meningeal  is  the 
vessel  which  is  torn,  but  through  the  opening  made  in  the  skull  one 
can  also  reach  the  posterior  branch  or  the  main  trunk  if  necessary. 

Having  entirely  removed  the  blood,  tied  the  ruptured  vessel, 
and  sutured  the  dura,  if  it  has  been  incised  or  torn,  we  replace  the 
osteo-tegumentary  flap  and  without  drainage  unite  the  edges  of  the 
soft  parts  all  around  with  interrupted  catgut  sutures. 

Removal  of  a  Button  of  Bone  with  the  Trephine. — By  removing 
a  button  of  bone  with  the  trephine  the  anterior  and  posterior 
branches  of  the  middle  meningeal  may  be  exposed  and  ligated. 

To  reach  the  anterior  branch  of  the  middle  meningeal,  an  in- 
cision, vertical,  is  made  through  the  skin,  muscle,  and  periosteum 
down  to  the  bone,  and  with  the  periosteum  elevator  the  surface  of 
the  bone,  corresponding  to  the  intersection  of  Vogt's  lines,  is  laid 
bare  (see  Fig.  19).  Instead  of  using  the  vertical  incision  this  area 
of  bone  may  be  exposed  by  turning  down  a  U-shaped  flap  with  its 


30  HEAD  AND  FACE. 

base  below  near  the  zygoma.  This  flap  includes  all  the  tissues  of 
the  scalp  and  the  periosteum,  and  is  detached  from  the  surface  of 
the  bone  with  an  elevator. 

The  trephine  is  then  used  to  remove  a  button  of  bone,  and 
thus  the  dura  is  exposed.  If  the  opening  is  not  sufficiently  large  it 
may  be  enlarged  with  the  rongeur  bone  forceps.  The  clot  is  usually 
fpund  between  the  dura  and  the  bone,  and  is  therefore  exposed  as 
soon  as  the  button  has  been  removed.  It  may,  however,  be  situated 
beneath  the  dura,  in  the  subdural  space,  and  it  may  thus  become 
necessary  to  incise  the  dura  in  order  to  reach  it.  After  clearing  out 
the  clot,  etc.,  the  ends  of  the  vessels  are  secured  and  the  incision  in 
the  soft  parts  closed.  This  operation  may  be  performed  more  quickly 
than  the  temporary  resection  of  the  skull,  but  it  does  not  give  as 
much  room,  and  a  further  disadvantage  is  that  it  usually  leaves  a 
permanent  defect  in  the  skull. 

To  expose  the  posterior  branch  of  the  middle  meningeal  a 
button  of  bone  may  be  removed  one  inch  above  and  one-half  inch 
posterior  to  the  external  auditory  meatus,  as  described  above.  This 
branch  is  but  seldom  injured. 

Craniectomy  (Linear  Craniotomy). — Making  linear  furrows 
in  the  skull  for  the  purpose  of  providing  space  to  permit  of  the  proper 
growth  of  the  brain,  in  cases  of  microcephalia  and  idiocy. 

This  operation  was  first  performed  by  Lannelongue.  It  may 
be  done  on  one  or  both  sides  of  the  skull  at  one  sitting:  one  side 
at  a  time  is  probably  preferable. 

A  longitudinal  incision  is  made  in  the  scalp  in  the  middle  line 
commencing  at  a  point  just  above  the  occipital  protuberance  and 
carried  forward  as  far  as  the  hair-line  of  the  scalp;  from  the  ante- 
rior end  of  this  a  second  curved  incision  may  be  made  reaching 
downward  and  outward  away  from  the  middle  line;  this  latter  in- 
cision is  also  placed  within  the  hair-line  of  the  scalp.  The  scalp 
is  then  raised  from  the  skull  with  the  elevator. 

Posteriorly,  just  above  the  occipital  protuberance,  an  opening 
is  made  in  the  skull  with  the  trephine,  about  one-half  inch  in  diam- 
eter, and  through  this  opening,  with  the  bone  forceps  (a  De  Vilbiss 
forceps  serves  the  purpose  very  satisfactorily),  a  furrow  is  cut  which 
is  carried  forward  to  within  an  inch  of  the  supra-orbital  ridge.  This 
channel  should  be  one-fourth  of  an  inch  wide  and  will  vary  from 
five  to  six  and  one-half  inches  in  length  and  should  be  placed  about 
three-fourths  of  an  inch  away  from  the  middle  line,  in  order  to  avoid 


OPERATIONS  UPON  THE  HEAD.  31 

the  longitudinal  sinus.  The  dura  is  detached  from  the  inner  surface 
of  the  skull  to  permit  the  use  of  the  bone  forceps,  but  it  should  not 
be  opened. 

From  either  end  of  the  longitudinal  furrow  in  the  bone  an 
additional  channel  may  be  cut,  reaching  downward  and  outward  for 
one  or  two  inches  away  from  the  middle  line. 

The  periosteum  is  cut  away  from  the  margins  of  the  furrows 
in  the  bone  to  prevent  reproduction  of  the  bone.  If  any  of  the  branches 
of  the  meningeal  are  injured  during  the  course  of  the  operation,  they 
may  be  surrounded  by  a  ligature  carried  in  a  curved  surgeon's  needle 
and  tied.  It  is  often  difficult  to  secure  these  branches  with  the  artery 
forceps,  and  thus  the  necessity  of  carrying  the  ligature  around  them  in 
the  needle. 

The  edges  of  the  incision  in  the  scalp  are  accurately  approxi- 
mated without  drainage,  to  insure  primary  healing. 

The  longitudinal  furrow  in  the  skull  is  usually  placed  to  the 
left  of  the  middle  line,  but  may  be  placed  upon  the  right  side  in- 
stead, if  this  appears  to  be  the  less  developed  side. 

Trephining  of  Frontal  Sinuses. — For  purpose  of  providing  drain- 
age in  cases  of  empyema.  A  curved  incision  commencing  in  the 
middle  line  above  the  root  of  the  nose  and  passing  outward  along  the 
upper  margin  of  the  orbit  corresponding  to  the  line  of  the  eyebrow. 
The  incision  passes  through  the  soft  parts,  including  the  periosteum 
down  to  the  bone.    The  bone  is  denuded  with  the  periosteum  elevator. 

The  anterior  bon}r  wall  of  the  sinus  is  penetrated  with  the  chisel 
and  mallet.  The  opening  is  placed  to  the  outer  side  of  the  middle 
line  and  above  the  margin  of  the  orbit.  The  mucous  lining  of  the 
sinus  which  is  thus  exposed  is  incised.  The  opening  in  the  bone  may 
be  enlarged  if  necessary  with  the  bone-forceps  or  chisel.  The  sinus 
may  be  curretted  with  the  sharp  spoon;  but  this  is  not  necessary  in 
all  cases.  A  probe  is  passed  into  the  sinus  and  down  through  the 
infundibulum  into  the  nasal  cavity.  This  passage  should  be  free  so 
as  to  permit  drainage.  The  infundibulum  takes  a  curved  course  from 
the  frontal  sinus  first  downward  and  somewhat  backward  and  then 
forward,  and  opens  under  the  front  portion  of  the  middle  turbinated 
bone.  Drainage  is  provided  by  drawing  a  tube  or  a  strip  of  gauze 
from  the  incision  down  through  the  infundibulum  and  out  through 
the  nose.  In  addition  the  sinus  is  loosely  packed  through  the  skin 
incision.  The  incision  is  closed  in  part.  If  both  sinuses  are  involved 
the  incision  can  be  carried  across  and  above  the  other  orbit,  and  the 


32  HEAD  AND  FACE. 

sinus  of  that  side  also  opened  by  gouging  away  its  front  wall.     The 
septum  between  the  two  sinuses  is  broken  down  with  the  chisel. 

THE  MIDDLE  FOSSA  OF  THE  SKULL. 

The  Anatomy  of  the  Middle  Fossa. — The  middle  fossa  of  the 
skull  is  narrow  in  the  middle  and  widens  out  upon  either  side.  It 
is  limited  in  front  by  the  posterior  border  of  the  lesser  wing  of  the 
sphenoid  and  by  the  optic  groove;  behind  by  the  dorsum  epiphii 
and  the  upper  border  of  the  petrous  portion  of  the  temporal  bone. 
The  upper  border  of  the  petrous  portion  is  marked  by  a  groove  for 
the  superior  petrosal  sinus  and  gives  attachment  to  the  tentorium 
eerebelli.  The  floor  of  the  middle  fossa,  in  the  middle  line,  consists 
of  the  upper  surface  of  the  body  of  the  sphenoid,  presenting  in 
front  the  optic  groove,  at  either  end  of  which  is  the  optic  foramen; 
behind  the  optic  groove  is  the  sella  turcica,  a  deep  depression  which 
lodges  the  pituitary  body  and  which  is  bounded  behind  by  the 
dorsum  epiphii ;  laterally  the  floor  of  this  fossa  consists  of  the  upper 
surface  of  the  great  wing  of  the  sphenoid,  the  anterior  surface  of 
the  petrous  portion  of  the  temporal,  and  a  part  of  the  squamous 
portion  of  the  temporal.  The  body  of  the  sphenoid  is  marked  upon 
either  side  by  a  groove  which  commences  behind  at  the  foramen 
lacerum  medium  (carotid  foramen)  and  terminates  in  front  at  the 
optic  foramen.    This  lodges  the  cavernous  sinus,  etc. 

The  foramen  lacerum  medium  is  formed  at  the  expense  of  the 
anterior  superior  surface  of  the  apex  of  the  petrous  portion  of  the 
temporal;  it  is  bounded  in  front  by  the  posterior  border  of  the 
great  wing  of  the  sphenoid  and  behind  by  the  apex  of  the  petrous 
portion;  through  this  opening  the  internal  carotid  artery  enters 
the  cranium.  Behind  and  external  to  this  foramen  the  antero- 
superior  surface  of  the  petrous  portion  presents  a  depression  in 
which  the  Gasserian  ganglion  rests.  In  front  of  and  exter-nal  to 
the  foramen  lacerum  medium,  in  the  posterior  part  of  the  great 
wing  of  the  sphenoid,  there  is  a  large  opening,  the  foramen  ovale. 
As  its  name  indicates,  this  opening  is  oval  in  shape,  its  long  diam- 
eter being  directed  from  without  inward  and  a  little  forward.  This 
opening  is  seen  externally  upon  the  base  of  the  skull  at  the  root 
of  the  pterygoid  process,  external  to  the  external  pterygoid  plate. 
Through  this  opening  the  inferior  maxillary  or  third  division  of  the 
fifth  nerve  emerges  from  the  cranial  cavity.     Just  external  to  the 


ANATOMY  OF  THE  MIDDLE  FOSSA. 


33 


Fig.  15. — Base  of  Skull  from  Within.  C,  cavernous  sinus;  CG,  Gasserian 
ganglion;  IP,  inferior  petrosal  sinus;  JF,  jugular  foramen;  L,  lateral  sinus; 
MA,  anterior  branch  of  middle  meningeal;  MP,  posterior  branch  of  middle 
meningeal;  SP,  superior  petrosal  sinus;  S,  sigmoid  (lateral)  sinus;  1,  first 
(ophthalmic)  division  of  fifth  nerve;  2,  second  (superior  maxillary)  division; 
3,  third  (inferior  maxillary)  division.  The  first  (ophthalmic)  division  rests 
upon  and  is  blended  with  the  wall  of  the  cavernous  sinus.  The  second  divis- 
ion lies  alongside  of,  but  is  not  connected  with,  the  wall  of  the  cavernous 
sinus. 


3 


34  HEAD  AND  FACE. 

foramen  ovale  and  a  little  behind  it,  in  the  apex  or  angle  of  the 
great  wing  of  the  sphenoid,  is  the  foramen  spinosum,  through  which 
the  middle  meningeal  artery  enters  the  skull.  From  this  opening 
a  groove  is  seen  running  outward,  marking  the  squamous  portion 
of  the  temporal  near  its  junction  with  the  petrous  portion;  this 
groove  lodges  the  posterior  branch  of  the  middle  meningeal  artery 
and  is  continued  upward  upon  the  side  of  the  skull  across  the  poste- 
rior inferior  part  of  the  parietal  bone.  Commencing  at  or  near  the 
foramen  spinosum  there  is  another  groove,  which  runs  forward  and 
outward  across  the  squamous  portion  of  the  temporal  and  the  great 
wing  of  the  sphenoid,  ascending  upon  the  side  of  the  skull,  across 
the  anterior  inferior  portion  of  the  parietal  bone;  in  this  groove 
rests  the  anterior  division  of  the  middle  meningeal  artery.  About 
one-half  inch  in  front  of  and  a  little  internal  to  the  foramen  ovale 
is  the  foramen  rotundum.  This  is  the  commencement  of  a  short 
canal  which  passes  obliquely  forward  through  the  great  wing  of  the 
sphenoid  and  opens  into  the  spheno-maxillary  fossa  through  the 
upper  part  of  its  posterior  wall;  the  superior  maxillary  or  second 
division  of  the  fifth  nerve  passes  through  this  canal.  Toward  the 
front  of  the  middle  fossa  we  have  the  sphenoidal  fissure  opening 
into  the  orbit ;  this  is  a  triangular  opening  between  the  free  border 
of  the  great  wing  and  the  under  surface  of  the  lesser  wing  of  the 
sphenoid,  its  base  being  inward  toward  the  body  of  the  sphenoid. 
Through  this  fissure  pass  the  third,  fourth,  and  the  ophthalmic  or 
first  division  of  the  fifth  nerve,  the  ophthalmic  vein,  etc. 

The  cavernous  sinus  is  a  wide,  loose,  thin-walled  canal  which  is 
situated  between  the  layers  of  the  dura  mater.  It  reaches  from  the 
apex  of  the  petrous  portion  of  the  temporal  bone  behind  to  the  inner 
end  of  the  sphenoidal  fissure  in  front,  being  lodged  in  the  cavernous 
groove  upon  the  side  of  the  body  of  the  sphenoid.  The  lumen  of 
the  cavernous  sinus  presents  a  peculiar  reticular  structure,  being 
broken  up  into  numerous  cellular  spaces  by  trabecular  and  septa 
which  pass  in  various  directions.  Anteriorly  the  cavernous  sinus 
receives  the  ophthalmic  vein,  and  posteriorly  it  joins  with  both 
petrosal  sinuses  and  communicates  with  the  pterygoid  plexus  through 
the  veins  which  enter  the  skull  through  the  foramina  ovale,  spino- 
sum, and  lacerum  medium.  The  external  border  of  the  cavernous 
sinus  corresponds  to  a  line  running  from  before  backward,  which 
would  just  skirt  the  inner  margin  of  the  foramen  rotundum  (see 
Fig.  15). 


ANATOMY  OF  THE  MIDDLE  FOSSA.  35 

The  internal  carotid  artery  enters  the  cranium  through  the 
foramen  lacerum  medium  and  passes  forward,  along  the  side  of  the 
body  of  the  sphenoid,  enveloped  by  the  cavernous  sinus,  the  sinus 
being,  as  it  were,  wrapped  entirely  around  the  artery.  (One  could 
not  wound  the  artery  in  this  situation  without  first  cutting  into  the 
sinus.)  Anteriorly,  at  the  inner  side  of  the  anterior  clinoid  process, 
the  internal  carotid,  after  giving  off  its  ophthalmic  branch,  turns 
upward  and,  passing  through  an  opening  in  the  dura  mater,  divides 
into  its  terminal  branches.  Along  the  outer  side  of  the  artery,  and 
therefore  also  inclosed  within  the  cavernous  sinus,  runs  the  sixth 
nerve.  In  the  outer  wall  of  the  cavernous  sinus  and  intimately 
united  to  it,  the  third,  the  fourth,  and  the  ophthalmic  or  first 
division  of  the  fifth  nerve  are  lodged;  these  structures  cannot  be 
separated  from  the  wall  of  the  sinus  without  tearing  it,  and  their 
relation  to  each  other  is  in  the  order  given  both  from  within  out- 
ward and  from  above  downward. 

The  fifth  nerve  at  its  origin  appears  upon  the  side  of  the  pons 
Varolii,  and  consists  of  a  thick  sensory  and  a  small  motor  root; 
these  pass  forward  through  an  oval  slit  in  the  dura  mater  and 
across  the  upper  border  of  the  petrous  portion  of  the  temporal 
bone,  near  its  apex,  into  the  middle  fossa  of  the  skull.  As  the 
roots  pass  over  the  upper  border  of  the  petrous  portion,  they  lie 
beneath  the  superior  petrosal  sinus.  In  its  course  the  nerve  lies 
outside  the  dura  mater,  extradural:  i.e.,  between  the  dura  mater 
and  the  base  of  the  skull.  Upon  reaching  the  front  surface  of  the 
petrous  portion  of  the  temporal  bone  the  sensory  root  presents  a 
swelling,  the  Gasserian  ganglion.  The  motor  root  takes  no  part  in 
the  formation  of  this  ganglion,  but  lies  underneath  it.  The  ganglion 
is  reddish  gray ;  crescentic  or  semilunar  in  shape ;  its  anterior  convex 
border  looks  forward,  downward,  and  outward.  It  is  14  to  22  mm. 
wide,  4  mm.  from  before  backward,  and  1 1/2  mm.  in  thickness. 

Given  off  from  the  anterior  border  of  the  ganglion  are  the  three 
divisions  of  the  fifth  nerve.  Of  these,  the  first,  or  ophthalmic,  the 
longest  and  thinnest  of  the  three,  is  the  most  internal  and  passes 
from  behind  forward  and  upward  along,  or  rather  in,  the  outer  wall 
of  the  cavernous  sinus,  entering  the  orbit  through  the  sphenoidal 
fissure.  On  account  of  its  intimate  relation  to  the  wall  of  the  sinus, 
any  attempt  to  separate  it  would  tear  the  wall  of  the  sinus;  it  is 
in  close  relation  with  the  third  and  fourth  nerves,  the  carotid  artery, 
and  the  sixth  nerve.    The  second,  or  superior  maxillary,  division  lies 


36 


HEAD  AND  FACE. 


external  to  the  preceding,  is  8  to  11  mm.  long,  and  passes  forward, 
entering  the  foramen  rotundum,  and  emerges  from  this  canal  in  the 
spheno-maxillary  fossa.  This  branch  lies  close  to  the  outer  edge 
of  the  cavernous  sinus,  hut  is  not  joined  to  it,  and  may  be  readily 
removed  without  clanger  to  the  sinus.  The  third,  or  inferior  maxil- 
lary, division,  the  most  external  of  the  three,  is  short  and  thick,  and 
passes  forward  and  outward,  leaving  the  skull  through  the  foramen 
ovale  in  company  with  the  motor  root.  The  motor  root  winds 
around  the  third  division  to  get  upon  its  outer  side,  the  two  be- 
coming joined  just  after  their  exit  through  the  foramen  ovale.  The 
ganglion  rests  in  the  depression  already  described  upon  the  front 
surface  of  the  petrous  portion  of  the  temporal  bone.     The  motor 


Fig.  16. — Transverse  Section  through  Floor  of  Middle  Fossa.  B,  bone  that 
forms  floor  of  middle  fossa;  CA,  internal  carotid  artery  inclosed  within  the 
trabeculated  cavernous  sinus;  CM,  cavum  Meckelii;  D,  dura  mater  lining 
floor  of  middle  fossa  and  roofing  over  cavum  Meckelii;  P,  dura  lining  floor  of 
cavum  Meckelii — periosteum;  3,  4,  51,  third,  fourth,  and  first  (ophthalmic) 
divisions  of  the  fifth  nerve,  lodged  in  the  wall  of  the  cavernous  sinus;  5U, 
5m,  second  (superior  maxillary)  and  third  (inferior  maxillary)  divisions  of 
fifth  nerve,  situated  between  the  dura  and  base  of  the  skull  in  the  cavum 
Meckelii;  6,  sixth  nerve  inclosed  within  cavernous  sinus  close  to  the  outer 
side  of  the  internal  carotid. 


root  of  the  nerve  takes  no  part  in  the  formation  of  the  ganglion, 
but  lies  beneath  it,  between  it  and  the  bone.  At  times  the  bone  is 
absent  in  this  location  and  under  such  circumstances  the  ganglion 
will  be  found  to  be  separated  from  the  carotid  artery  only  by  the 
fibrous  tissue  which  intervenes.  The  surface  of  bone  upon  which  the 
ganglion  and  its  three  divisions  rest  is  covered  by  the  periosteum.  The 
ganglion  and  its  divisions,  as  already  mentioned,  are  placed  extra- 
dural :  i.e.,  between  the  dura  mater  and  the  base  of  the  skull ;  the  dura 
roofs  them  over,  and  is  attached  to  the  margins  of  the  depression  in 


EXTIRPATION   OF  THE  GASSERIAN  GANGLION.  37 

which  the  ganglion  rests  and  to  the  floor  of  the  middle  fossa  of  the 
skull,  along  the  inner  margin  of  the  second  division  and  along  the 
outer  margin  of  the  third  division ;  so  that  not  only  the  ganglion,  but 
its  second  and  third  divisions  as  well,  are  thus  roofed  in.  This  space, 
in  which  the  ganglion  and  its  second  and  third  divisions  are  thus 
inclosed,  is  called  the  cavum  Meckelii.  Beyond  the  ganglion  and  its 
divisions  the  dura  is,  as  elsewhere,  closely  applied  to  the  surface  of  the 
bone.  The  ganglion  and  its  divisions  are  but  loosely  attached  to  the 
periosteum  which  covers  the  surface  of  the  bone  upon  which  they  rest 
(floor  of  cavum  Meckelii)  and  to  the  dura  mater  which  covers  them 
and  forms  the  roof  of  the  cavum  Meckelii. 

The  cavum  Meckelii  is  really  a  space  in  the  floor  of  the  middle 
fossa  of  the  skull  between  the  bone  and  the  non-attached  dura, 
which  lodges  the  ganglion  and  its  second  and  third  divisions. 

The  Gasserian  ganglion  is  in  relation,  internally,  with  the 
carotid  artery  and  cavernous  sinus.  Behind  the  ganglion  is  the 
superior  petrosal  sinus  underneath  which  the  roots  of  the  nerve 
must  pass  in  order  to  join  the  ganglion  as  it  rests  upon  the  front 
surface  of  the  petrous  portion.  The  superior  petrosal  sinus  is  con- 
tained in  the  edge  of  the  tentorium  cerebelli?  which  is  attached  to 
the  superior  border  of  the  petrous  portion. 

The  middle  meningeal  artery  enters  the  skull  through  the 
foramen  spinosum  just  external  to  and  a  little  behind  the  foramen 
ovale  (through  which  the  third  division  passes  out  of  the  skull)  and 
would  therefore  be  met  with  in  approaching  these  structures  through 
an  opening  in  the  side  of  the  skull. 

Extirpation  of  the  Gasserian  Ganglion  (Hartley-Krause). — The 
patient  is  placed  in  a  semirecumbent  position  with  the  head  turned 
partly  to  one  side.  A  horseshoe-shaped  flap,  consisting  of  the  in- 
tegument and  the  underlying  muscle  and  the  corresponding  segment 
of  bone,  is  turned  down. 

The  incision  passes  through  the  whole  thickness  of  the  soft 
parts,  including  the  periosteum,  down  to  the  bone.  This  incision 
commences  anteriorly,  just  above  the  zygoma,  and  a  good  finger's 
breadth  behind  the  external  angular  process;  it  is  carried  upward 
upon  the  temporal  region  describing  an  arc,  its  posterior  limb  ter- 
minating behind,  just  in  front  of  the  tragus.  Hemorrhage  should 
be  controlled  with  clamps.  The  flap  thus  marked  out  measures  in 
its  vertical  diameter  three  inches,  about  two  inches  across  its  widest 
part,  and  from  one  and  one-half  to  two  inches  at  its  base  which  is 


38  HEAD  AND  FACE. 

just  above  the  zygoma.  Corresponding  to  the  skin  incision  a  groove 
is  chiseled  all  around  in  the  bone;  this  groove  may  be  commenced  with 
a  circular  saw  and  completed  with  a  chisel.  The  Hartley  chisels  are 
probably  the  best  for  this  purpose,  as  they  cut  a  distinct  groove;  if 
an  ordinary  narrow  chisel  is  used,  it  should  be  held  quite  obliquely 
and  only  its  corner  engaged  in  the  bone  while  cutting.  This  groove 
should  be  deepened  to  the  same  extent  throughout  its  whole  length, 
going  over  it  several  times  before  finally  penetrating  through  the 
entire  thickness  of  the  bone.  The  groove  should  reach  entirely 
through  the  bone,  except  perhaps  at  its  lowest  part,  down  near  the 
zygoma.  Care  should  be  taken  not  to  injure  the  dura  with  the  chisel. 
The  De  Vilbiss  bone-forceps  may  be  used  instead  of  the  chisel  for 
the  purpose  of  cutting  the  bone  in  marking  out  the  flap. 

The  elevator  is  introduced  as  a  lever  into  the  upper  part  of  the 
groove  and  with  a  prying  motion  the  segment  of  bone,  with  the  soft 
parts  still  attached,  is  broken  through  at  its  base  and  turned  well  down 
over  the  zygoma;  if  the  opening  is  not  sufficiently  large,  more  bone 
may  be  cut  away  from  the  lower  margin  of  the  opening  with  the  bone 
forceps.  It  is  well  if  the  section  through  the  bone  is  so  made  that  its 
edge  presents  a  somewhat  beveled  margin,  so  that  it  may  fit  better  when 
replaced  (see  Fig.  14).  Through  this  opening  in  the  skull  the  dura 
mater  is  exposed,  the  anterior  branch  of  the  middle  meningeal  rami- 
fying upon  it  toward  the  front;  at  times  this  branch  is  torn  when  the 
plate  of  bone  is  reflected,  especially  if  the  groove  in  the  bone  in  Avhich 
the  vessel  is  lodged  is  unusually  deep ;  if  injured,  it  should  be  clamped 
and  tied.  Now,  with  the  fingers,  the  dura  is  separated  from  the  bone: 
floor  of  the  middle  fossa.  This  step  of  the  operation  may  be  executed 
without  much  difficulty  until  the  middle  meningeal  artery,  as  it  enters 
the  skull  through  the  foramen  spinosum,  is  encountered.  When  the 
vessel  is  exposed  it  should  be  secured  with  a  double  catgut  ligature  and 
divided ;  it  would  probably  answer  just  as  well  in  most  cases  to  ligate 
the  vessel  singly  or  else,  without  ligating  the  vessel,  to  plug  the  foramen 
spinosum  with  catgut,  and  then  divide  the  artery — its  distal  anasto- 
moses are  not  free.  The  field  of  operation  should  be  kept  clear  of  blood 
with  gauze  wipes  on  holders.  After  the  middle  meningeal  artery  has 
been  disposed  of  and  still  working  inward,  but  rather  more  cautiously, 
the  dura  mater  is  separated  from  the  base  of  the  skull  with  a  blunt 
elevator  or  with  a  small  gauze  pad  in  a  forceps,  at  the  same  time 
lifting  the  brain  away  from  the  base  of  the  skull  toward  the  vault. 
This  is  best  accomplished  with  the  aid  of  a  narrow,  polished,  right- 


EXTIRPATION   OF  THE  GASSERIAN   GANGLION.  39 

angle  retractor.  A  very  appropriate  instrument  has  been  made  espe- 
cially for  the  purpose.  With  it  the  brain  can  be  very  conveniently 
lifted  away  from  the  base  of  the  skull,  and  on  account  of  its  highly 
polished  surface  it  serves  as  a  reflector  at  the  same  time.  A  pad  of 
gauze  may  be  interposed  between  the  retractor  and  the  brain;  by  this 
means  the  hemorrhage  may  be  thus  somewhat  diminished.  The  hem- 
orrhage caused  by  separating  the  dura  mater  from  the  bone  is  some- 
times considerable.  It  may  be  controlled  by  a  few  minutes'  pressure 
with  a  gauze  pad  or  by  shifting  or  withdrawing  the  retractor  for  a  few 
minutes  and  allowing  the  brain  to  drop  back  upon  the  surface  of  the 
bone.  Thus  gradually  working  inward  we  reach  the  third  division  of 
the  nerve,  which  may  be  seen  passing  out  of  the  skull  through  the  fora- 
men ovale.  This  trunk  may  be  seized  with  a  narrow  forceps  and  iso- 
lated as  far  back  as  the  ganglion ;  it  serves  as  a  guide  to  the  ganglion. 
Without  cutting  this  trunk,  we  then  work  a  little  farther  inward, 
toward  the  middle  line,  until  we  meet  the  second  division.  This  is 
likewise  isolated  from  the  foramen  rotundum  backward  as  far  as  the 
ganglion.  The  upper  surface  of  the  ganglion  is  then  gradually  freed 
from  the  dura.  While  the  work  of  isolating  the  ganglion  is  being 
accomplished  the  brain  should  be  well  retracted:  lifted  away  from 
the  base  of  the  skull.  The  ganglion  can  be  separated  from  the  over- 
lying dura  with  a  blunt  periosteum  elevator;  one  may  seize  and  pull 
upon  the  third  division  of  the  nerve  and  use  this  as  a  guide  to  the 
ganglion.  It  may  be  necessary  to  cut  a  few  connective-tissue  bands, 
between  the  ganglion  and  the  dura,  with  the  scissors,  and  in  doing  this 
the  operator  may  accidentally  cut  into  the  dura;  this  accident,  how- 
ever, is  of  no  special  significance ;  there  may  escape  some  cerebro-spinal 
fluid,  but,  according  to  Tiffany,  this  is  rather  an  advantage.  There 
may  be  considerable  hemorrhage  occasioned  in  isolating  and  detaching 
the  ganglion,  but  this  may  again  be  controlled  by  pressure  with  the 
gauze  pad  or  by  shifting  the  retractor  or  allowing  the  brain  to  drop 
back  in  place  upon  the  bone  temporarily.  The  ganglion  should  be 
freed  as  far  back  as  the  superior  border  of  the  petrous  portion  of  the 
temporal  bone,  so  that  the  operator  may  be  able  to  see  the  white  trunk 
of  the  nerve  beyond  the  ganglion.  Care  should  be  exercised  in  freeing 
the  inner  part  of  the  ganglion,  on  account  of  the  proximity  of  this 
part  to  the  cavernous  sinus  and  to  the  carotid  artery.  The  operator 
should  finally  be  able  to  raise  the  detached  ganglion  away  from  the 
surface  of  the  bone  upon  which  it  rests  with  the  periosteum  elevator. 
At  times  this  surface  of  bone  is  absent,  and  the  ganglion  is  then  sepa- 


40  HEAD  AND  FACE. 

rated  from  the  artery  as  it  lies  in  the  carotid  canal  by  only  a  thin, 
cartilaginous  or  fibrous  layer;  therefore  one  should  avoid  any  rough- 
ness during  this  step  of  the  operation. 

The  ganglion,  being  finally  free  all  around,  is  seized  with  a  long, 
thin  artery  clamp,  and  in  doing  this  it  is  necessary  to  avoid  catching 
the  dura,  etc.,  at  the  same  time  in  the  grasp  of  the  forceps.  The  third 
and  second  divisions  are  then  cut,  either  with  the  scissors  or  with  a 
tenotome  close  to  their  foramina;  in  cutting  the  third  division,  the 
motor  branch  of  the  nerve  is  usually  divided  at  the  same  time  with  it. 
An  effort  should  be  made  to  avoid  cutting  the  motor  branch  as  the 
third  division  is  severed,  but  this  is  oftentimes  difficult  and  in  many 
cases  its  division  is  excusable.  When  the  third  division  is  cut  there 
may  be  considerable  venous  hemorrhage  from  the  small  meningeal 
branch  which  enters  the  skull  through  the  foramen  ovale;  this  can 
be  controlled  by  packing  or  by  shifting  the  retractor  or  by  allowing 
the  brain  to  drop  back  for  a  few  minutes  upon  the  base  of  the  skull. 

No  attempt  should  be  made  to  isolate  or  cut  the  first,  the  ophthal- 
mic, division  of  the  nerve  on  account  of  the  danger  of  doing  damage 
to  the  third,  fourth  or  sixth  nerve  and  to  the  cavernous  sinus,  and, 
besides,  this  branch  is  readily  torn  away  when  the  ganglion  is  twisted 
out. 

After  the  second  and  third  division  of  the  nerve  have  been  sev- 
ered the  ganglion,  in  the  grasp  of  a  long,  narrow  forceps,  is  slowly 
twisted  free,  tearing  it  away  from  the  first  division  and  usually  bring- 
ing away  with  it  a  portion  of  the  trunk  of  the  nerve  for  a  greater  or  less 
distance  beyond  the  ganglion.  Should  the  cavernous  sinus  be  torn,  the 
hemorrhage  is  profuse,  but  this  can  be  controlled  by  temporarily  pack- 
ing with  a  strip  of  gauze  and  allowing  the  brain  to  drop  back  into 
place  upon  the  base  of  the  skull. 

The  bone  is  finally  replaced  and  the  incision  in  the  soft  parts 
closed  with  suture.  It  is  well  to  introduce  a  strip  of  gauze  through 
the  posterior  part  of  the  opening  in  the  skull,  especially  if  there  is 
considerable  oozing,  for  the  purpose  of  drainage. 

This  operation  may  be  followed  by  ulcer  of  the  cornea  or  con- 
junctivitis, due  to  infection  or  the  entrance  of  dirt  which  is  not 
appreciated  by  the  patient  on  account  of  the  loss  of  sensation  in  the 
eye.  This  may  be  avoided  by  bandaging  the  eye  or  sealing  it  with  a 
watch-crystal. 

Ptosis,  paralysis  of  the  muscles  of  the  eye,  etc.,  may  occur  as  a 
result  of  injury  to  the  third,  fourth,  and  sixth  nerves.     These  com- 


EXTIRPATION   OF  THE  GASSERIAN  GANGLION.  41 

plications  may  be  avoided  by  keeping  away  from  the  first  division  of 
the  fifth  nerve  and  the  immediately  adjacent  third,  fourth,  and  sixth 
nerves  during  the  course  of  the  operation. 

Method  of  Cushixg. — The  zygomatic  arch  is  divided  and  dis- 
located downward  and  the  ganglion  is  approached  through  an  opening 
made  in  that  portion  of  the  great  wing  of  the  sphenoid  that  forms 
the  lower,  forward  part  of  the  temporal  fossa.  It  is  not  necessary  to 
divide  or  ligate  the  meningeal  artery  in  this  operation. 


Fig.  17. — Zygomatic  Arch  Resected  (Gushing).  Opening  in  lower  anterior 
part  of  temporal  fossa.  Dura  supporting  anterior  branch  of  middle  meningeal 
exposed.    B,  edge  of  opening  in  skull;    M,  cut  edge  of  temporal  muscle. 


A  horseshoe-shaped  incision  is  made  upon  the  side  of  the  head; 
its  base,  4  cm.  long,  corresponds  to  the  zygoma;  its  arch  reaches 
upward  for  a  distance  of  about  5  cm.,  the  highest  part  of  the  in- 
cision is  just  above  the  pinna  of  the  ear.  The  flap  of  skin  and  fat  is 
detached  and  reflected  downward  below  the  level  of  the  zygoma,  in  this 
way  exposing  the  fascia  covering  the  temporal  muscle.  Concentric  to 
and  just  inside  the  skin  incision  the  temporal  fascia  is  divided.  The 
periosteum  corresponding  to  the  outer  surface  of  tEe  zygomatic  arch 
is  incised  and  peeled  off  the  bone,  leaving  the  attachment  of  the 
masseter  to  its  under  surface  intact  and  the  arch  then  divided  with 


42  HEAD  AND  FACE. 

bone-forceps,  both  anteriorly  and  posteriorly,  and  dislocated  down- 
ward. Again,  corresponding  to  and  inside  the  skin  incision,  the  tem- 
poral muscle  is  incised  and  detached  downward  away  from  the  surface 
of  the  bone. 

A  small  opening  is  made  in  the  bone  in  the  lower  anterior  part 
of  the  temporal  fossa  and  this  is  enlarged  with  the  rongeur  forceps 
until  an  opening  3  cm.  in  diameter  is  obtained.  The  dura  mater  sup- 
porting the  middle  meningeal  artery  is  thus  exposed,  the  artery  passing 
obliquely  forward  and  upward  across  the  opening  in  the  skull. 

The  dura  with  the  artery  uninjured  is  raised  away  from  the  base 
of  the  middle  fossa  working  inward  with  the  elevator  until  the  loca- 
tion of  the  foramen  ovale  is  reached.  In  this  situation  the  dura  is 
found  more  firmly  attached  to  the  bone.  The  dura  mater  envelope 
underneath  which  the  ganglion  and  its  three  intra-cranial  branches 
are  lodged  is  split  or  detached,  working  from  before  backward,  from 
the  region  of  the  foramen  rotundum  to  the  foramen  ovale,  continuing 
until  the  three  trunks  and  the  ganglion  back  as  far  as  its  sensory  root 
are  exposed.  With  the  periosteum  elevator  the  ganglion  and  the  three 
branches  are  detached  from  their  bed.  After  the  second  and  third 
trunks,  the  superior  and  inferior  maxillary  branches,  have  been  sepa- 
rated the  operator  proceeds  to  separate  the  first,  the  ophthalmic  branch. 
This  is  the  innermost  of  the  three  and  lies  in  close  relation  with  the 
cavernous  sinus  and  the  sixth  nerve.  The  separation  of  this  branch 
is  commenced  behind  the  ganglion  near  the  sensory  root,  working 
forward  with  the  elevator  and  avoiding  the  cavernous  sinus  and  the 
sixth  nerve.  Finally  the  ganglion  and  the  three  trunks  can  be  lifted 
free  upon  the  elevator. 

The  ganglion  is  grasped  behind  near  its  sensory  root  with  a 
long,  thin  forceps  and  raised  up  out  of  its  bed,  and  the  three  branches 
are  then  cut  close  to  their  foramina,  etc.,  and  the  ganglion  and  sensory 
root  twisted  free,  bringing  the  ganglion,  the  three  divisions  of  the 
nerve,  and  part  of  the  sensory  root  away  in  the  grasp  of  the  forceps. 

The  soft  parts  are  sutured  back  in  place;  it  is  unnecessary  to 
wire  the  detached  piece  of  zygoma.  The  eye  is  protected  with  a  sheet 
of  gutta  percha  and  dressings  applied.  As  a  rule,  it  is  not  necessary 
to  make  any  provision  for  drainage. 

Extirpation  of  the  Gasserian  Ganglion  (Rose- Andrews). — The 
incision  commences  at  a  point  near  the  external  angular  process, 
curving  backward  above  the  zygoma  to  a  point  just  in  front  of  the 
ear,  whence  it  extends  downward  to  near  the  angle  of  the  jaw.     This 


EXTIRPATION   OF  THE  GASSERIAN   GANGLION. 


43 


incision  penetrates-  through  the  skin  and  fat  only,  and  pams  should 
be  taken  to  avoid  injuring  the  parotid  gland,  Stenson's  duct,  and 
the  facial  nerve.  The  temporal  artery,  as  it  ascends  in  front  of  the 
ear,  may  be  divided,  in  which  case  it  will  be  necessary  to  ligate  it. 
The  flap  which  is  thus  outlined  is  reflected  downward  sufficiently  to 


Fig.  18.— Resection  «f  the  Gasserian  Ganglion,  etc.  EL,  Krbnlein-Liicke 
Incision;  RA,  Rose- Andrews  incision.  Dotted  lines  represent  the  lines  of 
division  through  the  bones;  drill  holes  for  subsequent  wiring  of  the  frag- 
ments. 


expose  the  zygomatic  arch.     The  temporal  fascia*  is  incised  along  the 
upper  border  of  the  zygomatic  arch. 

The  next  step  of  the  operation  is  the  division  of  the  zygomatic  arch 
with  the  chain  saw  or  Gigli  saw,  both  in  front  and  behind,  and  the  seg- 
ment of  bone  which  is  thus  resected,  together  with  the  attached  masseter 


44  HEAD  AXD  FACE. 

muscle,  is  then  reflected  downward.  Before  dividing  the  zygomatic  arch 
holes  should  be  drilled  through  the  bone  corresponding  to  the  intended 
line  of  section,  so  that  it  may  be  wired  back  in  place  after  the  operation 
has  been  completed.  When  this  flap,  including  the  detached  segment  of 
the  zygomatic  arch  and  the  masseter  muscle,  is  turned  down,  the  cora- 
coid  process  of  the  lower  jaw  and  the  tendon  of  the  temporal  muscle, 
which  is  attached  to  it,  are  exposed.  The  coracoid  process  is  divided, 
first  drilling  holes  for  subsequent  wiring,  and  together  with  the  at- 
tached tendon  of  the  temporal  muscle,  this  is  turned  upward.  There  is 
now  exposed  the  internal  maxillary  artery  passing  from  below,  forward, 
and  upward  across  the  outer  surface  of  the  external  ptenrgoid  muscle. 
This  vessel  is  tied  double  and  divided.  With  the  periosteum  elevator 
the  external  pterygoid  muscle  is  separated  from  its  attachment  to  the 
under  surface  of  the  great  wing  and  from  the  outer  surface  of  the 
external  pterygoid  plate  of  the  sphenoid.  All  hemorrhage  should  be 
controlled  by  ligature  or  pressure  as  the  operation  progresses  step  by 
step.  With  the  finger  in  the  wound  the  sharp  edge  of  the  external 
pterygoid  plate  is  felt  for  and  recognized  and,  tracing  this  upward 
as  a  guide,  we  feel  or  see  the  foramen  ovale  at  its  base  (see  Fig.  21). 

A  trephine  of  small  diameter  is  applied  to  the  base  of  the  skull 
(to  the  portion  corresponding  to  the  under  surface  of  the  great  wing 
of  the  sphenoid  which  has  been  laid  bare  by  detaching  the  external 
pterygoid  muscle)  anterior  and  a  little  external  to  the  foramen  ovale, 
and  here  a  small  button  of  bone  is  removed.  After  this  button  of  bone 
has  been  removed  the  bridge  of  bone  remaining  between  the  trephine 
opening  and  the  foramen  ovale  is  cut  away  with  a  rongeur  bone  forceps. 
The  third  division  of  the  fifth  nerve  is  seized  with  a  hook  and  drawn 
out  through  the  opening  in  the  skull  to  serve  as  a  guide  to  the  G-as- 
serian  ganglion,  and  then  the  second  division  of  the  nerve  is  also  seized 
with  the  hook  and  pulled  out  through  the  same  opening.  These  trunks 
are  both  divided  and  used  as  guides  to  the  ganglion,  which  lies  in  a 
direction  backward  and  inward  from  the  foramen  ovale,  within  the 
skull,  upon  the  apex  of  the  petrous  portion  of  the  temporal  bone.  The 
cut  ends  of  the  nerves,  still  attached  to  the  ganglion,  are  steadied  in  the 
grasp  of  a  long,  narrow  artery  forceps,  and  with  a  curette  which  is 
introduced  through  the  opening  in  the  skull,  the  ganglion  is  destroyed 
and  scooped  out. 

The  technique  of  this  operation  is  difficult,  as  it  is  almost  im- 
possible to  reach  the  ganglion.  There  is  liability  to  profuse  hemor- 
rhage which  may  be  extremely  difficult  to  control  and  also  to  injury  of 


SURGICAL  ANATOMY  OF  THE  MASTOID  REGION".  45 

the  Eustachian  tube.  If  the  Eustachian  tube  is  injured  during  the 
course  of  the  operation,  the  danger  of  infection  is  great.  Oozing 
can  be  stopped  by  pressure  with  a  gauze  pad.  When  the  operation 
has  been  finished,  the  parts  are  replaced,  the  coracoid  process  being 
wired  to  the  ramus  of  the  jaw  and  the  detached  segment  of  the 
zygomatic  arch  fixed  in  place  with  wire  sutures.  The  incision  in  the 
skin  is  closed  with  a  sufficient  number  of  silk  sutures. 

THE  MASTOID  REGION  AND  THE  EAR. 

The  mastoid  region  and  the  ear  are  intimately  associated  with 
each  other  clinically. 

The  Surgical  Anatomy  of  the  Mastoid  Region. — The  mastoid 
region  is  that  part  of  the  skull  which  corresponds  to  the  mastoid 
portion  of  the  temporal  bone. 

The  integument  of  this  region  is  thin  and  contains  very  little 
fat;  its  blood-supply  is  derived  from  the  posterior  auricular  artery, 
which  ascends  just  behind  the  ear.  The  occipital  artery  ascends 
beneath  the  sterno-mastoid  muscle  and  becomes  superficial  midway 
between  the  mastoid  process  and  the  external  occipital  protuberance, 
whence  it  is  continued  upward  upon  the  back  of  the  skull. 

The  surface  of  the  mastoid  is  uneven  and  perforated  by  a  variable 
number  of  small  vascular  openings.  At  the  back  part  of  the  mastoid 
portion,  at  or  just  in  front  of  the  suture  line  between  it  and  the 
occipital  bone,  there  is  an  opening,  the  mastoid  foramen.  Through 
this  a  small  vein  passes  into  the  lateral  sinus  and  a  small  arterial 
branch  from  the  occipital  artery  to  the  dura  mater. 

The  inner  surface  of  the  mastoid  portion  presents  a  wide  groove, 
curving  from  above  downward  with  the  convexity  forward,  which 
lodges  the  sigmoid  (lateral)  sinus.  This  groove  is  located  about  half 
an  inch  behind  the  posterior  border  of  the  external  auditory  meatus, 
and  presents  the  opening  of  the  mastoid  foramen. 

The  mastoid  portion  is  prolonged  below  in  a  teat-like  process. 
It  is  larger  in  muscular  subjects ;  it  is  comparatively  small  in  the 
child.  The  structure  of  this  process  varies.  Its  cortex  may  be  thin 
or  may  be  thick  and  very  hard  like  ivory.  The  interior  of  the  mas- 
toid process  is  at  times  found  to  consist  of  a  number  of  cellular 
recesses  lined  with  mucous  membrane  and  communicating  with  each 
other  and,  through  the  antrum,  with  the  middle  ear,  or  it  may 
be  composed  of  ordinary  spongy  bone,  or  occasionally  it  is  very  dense 


46  HEAD  AND  FACE. 

and  hard,  resembling  ivory.  There  is  always  present,  however,  even 
in  the  newborn,  at  least  one  space,  the  antrum.  The  mastoid  antrum 
is  a  space,  varying  in  size  from  a  small  pea  to  a  small  bean,  which 
is  found  in  the  mastoid  process  just  behind  the  tympanic  cavity; 
these  two  spaces  communicate  with  each  other  through  an  opening 
in  the  upper  part  of  the  posterior  wall  of  the  tympanum.  The  roof 
of  the  antrum  is  formed  by  the  same  plate  of  bone  that  forms  the 
roof  of  the  tympanum.  The  antrum  is  lined  with  mucous  mem- 
brane, which  is  continuous  with  that  of  the  tympanum.  The  antrum 
is  practically  a  part  of  the  tympanic  cavity,  and  an  inflammatory 
process  originating  in  the  tympanum  may  readily  extend  and  involve 
the  antrum,  etc.  Externally  the  antrum  may  be  located  upon  a 
level  with  the  upper  margin  of  the  external  auditory  meatus  and 
between  5  and  10  mm.  (say,  one-fourth  inch)  behind  this  opening, 
and  is  usually  found  at  a  depth  of  from  12  to  18  mm.  beneath  the 
external  surface  of  the  bone.  In  very  young  children  the  antrum  is 
comparatively  large  and  very  close  to  the  surface  of  the  bone,  just 
behind  the  upper  margin  of  the  external  auditory  meatus. 

The  outer  margin  of  the  bony  portion  of  the  auditory  canal  is 
marked  above  and  behind  by  a  spine,  the  spina  supra  meatum;  this 
spine  is  readily  recognized  after  the  soft  parts  have  been  incised  and 
separated,  and  may  be  used  as  a  landmark  in  locating  the  antrum. 
The  antrum  lies  upon  the  same  level  as  the  spine,  but  about  one- 
fourth  inch  posterior  to  it. 

The  mastoid  process  is  usually  made  up  of  a  number  of  cellular 
spaces,  the  pneumatic  mastoid,  all  lined  with  mucous  membrane  and 
communicating  through  the  antrum  with  the  middle  ear  (tympanum); 
these  reach  to  the  tip  of  the  process  and  often  penetrate  beyond  the 
limits  of  the  mastoid  process  into  the  occipital  bone  or  zygomatic 
process  or  they  may  extend  backward  into  the  mastoid  portion  proper, 
pretty  close  to  the  groove  which  lodges  the  sigmoid  sinus,  so  that 
there  may  be  but  a  very  thin  shell  of  bone  separating  the  mastoid 
cells  from  the  sinus.  Mastoids  vary  in  different  people  and  upon 
opposite  sides  in  the  same  person  as  to  the  extent  to  which  these 
cells  are  developed.  They  begin  to  develop  early  in  life,  but  the 
age  differs  at  which  they  are  found  fully  developed.  From  five  years 
on  they  are  fairly  well  marked,  and  it  is  said  that  at  the  age  of 
fifteen  years  they  are  all  developed  down  to  the  tip  of  the  process. 
Some  say  that  they  do  not  reach  complete  development  until  a  few 
vears  later.     Occasionally  the  septa  may  undergo  a  process  of  rare- 


ANATOMY  OF  THE  EAR. 


47 


faction,  the  septa  gradually  disappearing  and  the  spaces  opening  into 
each  other  until  they  are  all  combined  in  one  large  space  represented 
by  the  antrum.  Instead  of  as  above  described,  the  structure  of  the 
bone  may  be  spongy  or  it  may  be  excessively  dense  and  without  spaces, 
resembling  ivory. 


Fig.  19.— Side  of  Skull.  A,  position  of  opening  in  skull  to  expose  the  ante- 
rior branch  of  the  middle  meningeal  (Vogt's  lines) ;  G,  position  of  opening  for 
cerebellar  abscess;  MA,  location  of  mastoid  antrum  (directly  in  front  of  circle 
MA  Is  the  spina  supra  meatum) ;  P,  opening  to  expose  the  posterior  branch 
of  middle  meningeal;  R,  Reid's  base-line  continued  backward  to  external 
occipital  protuberance;  8,  dotted  lines  represent  course  of  lateral  (sigmoid) 
sinus;  T8,  opening  in  the  skull  for  abscess  of  the  temporo-sphenoidal  lobe. 


The  Anatomy  of  the  Ear.  —  Changes  that  occur  in  the  first 
visceral  cleft  result  in  the  formation  of  the  external  and  middle 
ear.  The  internal  ear,  labyrinth,  etc.,  are  formed  within  the  sub- 
stance of  the  petrous  portion  of  the  temporal  hone.  The  external 
fossa,  or  cleft,  develops  into  the  external  auditory  canal  and  auricle; 


48  HEAD  AND  FACE. 

the  internal  fossa,  or  cleft,  which  opens  into  the  pharynx,  becomes 
the  Eustachian  tube  and  tympanum.  Where  the  funduses  of  these 
clefts,  or  fossae,  meet,  their  walls  coalesce  and  thus  form  the  drum, 
the  partition  between  the  external  and  the  middle  ear.  The  margin 
of  the  outer  opening  of  the  external  cleft,  or  fossa,  becomes  thick- 
ened and  nodulated,  and  these  nodules,  coalescing,  form  the  external 
ear. 

The  hearing  apparatus  may  be  divided  into  the  external  ear, 
which  includes  the  auricle,  external  auditory  canal,  and  drum;  the 
middle  ear,  tympanum,  which  communicates  with  the  pharynx 
through  the  Eustachian  tube;  and  the  internal  ear,  labryinth,  etc., 
inclosed  within  the  petrous  portion  of  the  temporal  bone. 

The  auricle  is  made  up  of  a  cartilaginous  plate  considerably 
folded  upon  itself  and  covered  with  skin;  it  consists  of  several  parts. 
It  is  attached  to  the  side  of  the  head  by  ligamentous  bands;  one 
of  these  passes  forward  to  the  root  of  the  zygoma;  the  other  back- 
ward to  the  mastoid  process.  Its  blood-supply  is  derived  from 
branches  which  are  given  off  by  the  temporal  artery  in  front  and 
the  posterior  auricular  behind.  The  supply  is  very  abundant,  and 
therefore  wounds  of  the  ear  heal  kindly. 

The  external  auditory  canal  is  about  one  inch  (24  mm.,  Trolsch) 
in  length;  its  outer  portion,  comprising  one-third  of  its  length,  is 
cartilaginous  and  continuous  with  the  auricle;  the  inner  part,  com- 
prising two-thirds  of  its  length,  is  bone.  The  course  of  the  canal 
is  transverse,  but  it  suffers  two  curves:  one,  in  its  cartilaginous  part, 
with- its  convexity  forward;  the  second  at  the  junction  of  the  carti- 
laginous and  bony  parts,  with  its  convexity  backward;  this  junction 
is  the  narrowest  part  of  the  canal,  and  is  called  the  isthmus. 

To  expose  the  drum,  the  auricle  is  drawn  upward,  backward,  and 
outward  away  from  the  side  of  the  head. 

In  the  newborn  child  there  is  no  bony  portion  to  the  external 
auditory  canal,  this  part  being  represented  only  by  a  ring  of  bone 
into  which  the  drum  is  fitted.  This  bony  ring,  the  auditory  process, 
is  incomplete,  and  is  applied  against  the  depressed,  hollowed-out 
under  surface  of  the  squamous  portion  of  the  temporal,  which  thus 
completes  the  ring.  At  this  early  age  the  drum  is  very  near  the  sur- 
face of  the  body,  there  being  no  depth  to  the  bony  auditory  canal. 
As  the  child  grows,  the  bony  ring,  the  auditory  process,  broadens  out, 
and  in  the  adult  is  represented  by  the  external  auditory  process, 
which  corresponds  to  its  outer  edge,  and  by  the  vaginal  process,  this 


ANATOMY  OF  THE  EAR.  49 

latter  forming  the  lower  and  anterior  wall  of  the  bony  portion  of  the 
auditory  canal  and  the  back  part  of  the  floor  of  the  glenoid  cavity. 
The  upper  wall  of  the  auditory  canal  is  formed  by  the  grooved  under 
surface  of  the  squamous  portion  of  the  temporal  bone.  The  miter 
edge  of  the  auditory  process  is  rough,  and  to  it  is  attached,  by  firm 
connective  tissue,  the  cartilaginous  part  of  the  auditory  canal. 

The  skin  which  lines  the  interior  of  the  auditory  canal  is  con- 
tinuous with  that  which  covers  the  surface  of  the  drum. 

The  bony  part  of  the  external  auditory  canal  is  in  relation, 
above,  with  the  middle  fossa  of  the  skull,  from  which  it  is  separated 
by  a  thin,  cellular  plate  of  bone,  part  of  the  squamous  portion  of 
the  temporal;  behind,  it  is  in  relation  with  the  mastoid  system  of 
cells,  and,  in  front,  with  the  condyle  of  the  lower  jaw  and  the  parotid 
gland. 

Blows  upon  the  chin  may  be  transmitted  through  the  lower  jaw 
to  the  condyle,  and  in  this  way  may  injure  the  auditory  canal,  so  that 
there  may  be  an  issue  of  blood  from  the  external  auditory  meatus. 
Purulent  processes  involving  the  auditory  canal  may  present  cere- 
bral complications,  especially  in  children,  without  the  middle  ear 
being  involved,  the  infection  in  these  cases  passing  through  the  roof 
of  the  auditory  canal  directly  into  the  cavity  of  the  skull. 

The  drum  is  the  septum  between  the  external  and  the  middle 
ears.  It  is  made  up  of  skin  externally,  and,  internally,  of  the  mu- 
cous membrane  of  the  tympanum;  interposed  between  those  two  is 
a  layer  of  connective  tissue.  The  drum  is  set  in  a  bony  ring,  and 
forms  the  greater  part  of  the  external  wall  of  the  tympanum.  -  It  is 
set  obliquely  and  in  such  a  way  that  its  outer  surface  looks  down- 
ward, forward,  and  outward;  the  anterior  wall  of  the  external  audi- 
tory canal  is  thus  longer  than  the  upper,  posterior  wall. 

The  middle  ear  consists  of  the  tympanum  and  adjoining  air- 
cells  and  the  Eustachian  tube. 

The  tympanum  is  a  wedge-shaped  cavity  separated  from  the 
external  auditory  canal  by  the  drum  and  communicating  by  an 
opening  in  its  anterior  end,  through  the  Eustachian  tube,  with  the 
pharynx.  In  the  anterior  part  is  also  seen  the  Glaserian  fissure, 
through  which  the  middle  ear  communicates  with  the  glenoid  cavity 
and  through  which  the  chorda  tympani  leaves  the  tympanum. 

The  carotid  artery,  surrounded  by  a  venous  plexus,  traverses  a 
canal,  in  the  temporal  bone,  which  is  located  just  in  front  of  the 
tympanum  and  which  is  separated  from  this  cavity  by  a  very  thin 


50  HEAD  AND  FACE. 

plate  of  bone  that  is,  at  times,  perforated.  Behind,  the  tympanum 
communicates  with  the  mastoid  antrum  through  an  opening  in  the 
upper  part  of  its  posterior  wall.  The  inner  wall  of  the  tympanum, 
that  opposite  the  drum,  presents,  toward  the  front,  the  promontory; 
behind  this,  two  openings,  one  above,  the  foramen  ovale,  and  an- 
other below  and  a  little  behind,  the  foramen  rotundum.  The  laby- 
rinth is  located  beneath  this  inner  wall,  in  the  petrous  portion  of 
the  temporal  bone.  This  inner  wall  presents  a  smooth,  curved  ridge 
above  the  foramen  ovale  which  runs  backward  and  downward  toward 
the  back  of  the  tympanum;  it  corresponds  to  the  position  of  the 
Fallopian  canal  which  lodges  the  facial  nerve  in  its  course  through 
the  petrous  portion  of  the  temporal  bone.  The  layer  of  bone  which 
separates  the  nerve  from  the  cavity  of  the  tympanum  is  sometimes  very 
thin  or  perforated.  The  tympanum  communicates  with  the  posterior 
fossa  of  the  skull  through  the  labyrinth  and  the  internal  auditory 
canal,  which  is  traversed  by  the  facial  and  auditory  nerves.  The  bulb 
of  the  jugular  vein  is  lodged  in  the  depression  in  the  temporal  bone 
beneath  the  floor  of  the  tympanum.  The  layer  of  bone  which  forms 
the  floor  of  the  tympanum  is  usually  comparatively  thick,  though  it 
may  be  very  thin,  perforated,  or  entirely  absent.  In  the  latter  case 
the  mucous  membrane  lining  the  floor  of  the  tympanum  and  the  wall 
of  the  internal  jugular  vein  would  be  in  direct  contact  with  each  other. 
Through  small  openings  in  the  floor  of  the  tympanum,  Jacobson's 
nerve,  a  branch  from  the  glosso-pharyngeal,  and  some  small  arterial 
and  venous  branches  enter  the  tympanum. 

The  roof  of  the  tympanum,  the  most  common  link  between  dis- 
ease of  the  ear  and  intracranial  complications,  is  a  thin,  cellular 
plate  of  bone;  it  may  be  very  thin,  perforated,  or  entirely  absent. 
This  plate  of  bone  reaches  from  the  petrous  portion  of  the  temporal 
bone  over  to  the  inner  surface  of  the  squamous  portion,  where  a 
suture  line,  petroso-squamous,  exists.  In  the  child  this  suture  line 
is  open  and  contains  a  process  of  dura  mater  which  joins  with  the 
mucous  membrane  lining  of  the  tympanum  and  carries  blood-vessels 
which  take  part  in  the  supply  of  both  these  membranes.  This  con- 
dition, although  not  so  visible,  continues  to  exist  in  the  adult.  This 
same  thin  layer  of  bone,  which  forms  the  roof  of  the  tympanum, 
reaches  backward  and  forms  also  the  roof  of  the  mastoid  antrum. 
The  roof  of  the  tympanum  and  antrum  forms  part  of  the  floor  of 
the  middle  fossa  of  the  skull,  and  is  in  relation  with  the  dura  mater, 
etc.,  and  with  the  temporo-sphenoidal  lobe  of  the  brain. 


ANATOMY  OF  THE  EAR.  51 

The  course  of  the  facial  nerve  through  the  temporal  bone  and 
its  relation  to  the  tympanum  and  the  mastoid  antrum  are  impor- 
tant. The  nerve  enters  the  internal  auditory  canal  in  company  with 
the  auditory  nerve,  and  passes  in  a  direction  forward  and  outward, 
reaching  the  inner  wall  of  the  middle  ear,  tympanum,  just  above 
the  foramen  ovale;  here  it  makes  a  turn  and  runs  backward  and 
downward  in  the  aqueductus  Fallopii.  The  course  of  this  canal  is 
indicated  by  a  prominent  linear  elevation  upon  the  inner  wall  of 
the  tympanum  just  above  the  foramen  ovale;  at  the  back  of  the 
tympanum,  the  nerve,  as  it  curves  downward  and  still  contained 
within  the  aqueductus  Fallopii,  is  situated  but  a  short  distance  in 
front  of  the  antrum.  It  continues  its  course  through  the  substance 
of  the  petrous  portion  of  the  temporal  bone,  emerging,  externally, 
upon  the  base  of  the  skull,  through  the  stylo-mastoid  foramen.  This 
foramen  is  located  internal  to,  and  a  little  in  front  of,  the  base  of 
the  mastoid  process.  Just  before  the  facial  nerve  emerges  from  the 
stylo-mastoid  foramen  and  while  still  contained  within  the  canal,  it 
gives  off  a  branch,  the  chorda  tympani,  which  passes  forward  and 
upward  through  a  separate  canal  in  the  petrous  portion,  and  enters 
the  tympanum  through  an  opening  in  its  posterior  wall,  near  the 
drum;  it  runs  forward  through  the  tympanic  cavity,  being  covered 
by  mucous  membrane,  and  escapes  through  the  Glaserian  fissure,  a  slit 
in  the  anterior  part  of  the  floor  of  the  tympanum,  into  the  glenoid 
cavity. 

The  stylo-mastoid  artery,  derived  from  the  posterior  auricular, 
enters  the  stylo-mastoid  foramen  to  supply  the  facial  nerve  and  also 
the  mucous  membrane  of  the  tympanum. 

The  Eustachian  tube  reaches  from  the  tympanum  to  the  phar- 
ynx; its  outer  one-third  is  bony;  its  inner  two-thirds,  cartilaginous. 
Where  these  join,  the  tube  is  narrowest:  the  isthmus.  The  tube 
opens  into  the  anterior  end  of  the  tympanum,  near  the  drum;  its 
inner  end  opens  into  the  pharynx  above  the  soft  palate  and  just 
behind  the  posterior  border  of  the  inferior  turbinated  bone.  The 
walls  of  the  cartilaginous  portion  of  the  tube  are  usually  in  contact 
and  the  tube  is  thus  closed.  To  ventilate  the  tympanum,  muscular 
action,  which  will  open  the  pharyngeal  end  of  the  tube,  is  required. 
This  is  accomplished  by  the  muscles  of  the  soft  palate:  the  tensor 
and  the  levator  palati. 


52  HEAD  AND  FACE. 

OPERATIONS  UPON  THE  MASTOID,  ETC. 

Wilde's  Incision. — This  consists  of  a  simple  incision  through 
the  soft  parts,  including  the  periosteum,  down  to  the  bone.  It  is 
placed  1  cm.  behind  and  parallel  with  the  auricle,  and  reaches  from 
the  base  of  the  mastoid  process  to  its  apex.  Usually  no  vessels  are 
cut  and  it  is  not  necessary  to  apply  any  ligatures.  It  is  often  suffi- 
cient in  very  young  children. 

Drilling  into  the  Antrum. — An  incision  is  made  through  the 
soft  parts  down  to  the  bone,  as  in  the  preceding  operation,  and  a 
channel  drilled  through  the  bone  down  into  the  antrum.  The  drill 
is  placed  upon  the  mastoid,  upon  a  level  with  the  upper  margin  of 
the  external  auditory  meatus,  spina  supra  meatum,  and  rather  less 
than  one-half  inch  posterior  to  it,  and  a  canal  is  then  drilled  through 
the  bone  in  a  direction  downward,  forward,  and  inward  toward  the 
antrum;  this  canal  should  not  be  carried  much  deeper  than  one-half 
inch.  This  operation  is  not  one  to  be  recommended,  as  it  is  uncer- 
tain and  may  be  dangerous,  especially  if  one  proceeds  deeper  than 
one-half  inch.  It  is  much  more  satisfactory  to  make  a  free  opening 
into  the  antrum  with  the  chisel. 

To  Open  into  and  Drain  the  Antrum. — The  patient  is  placed 
with  the  head  upon  the  side  resting  upon  a  thin  sand-bag. 

Eegardless  of  any  condition  that  may  complicate  mastoid  dis- 
ease, the  first  step  should  always  consist  in  opening  into  the  antrum. 
(Bacon,  Schwartz.) 

An  incision  is  made  1  cm.  (Schwartz) — one-third  inch — behind 
the  attachment  of  the  auricle,  through  the  soft  parts,  including  the 
periosteum,  down  to  the  surface  of  the  bone,  and  reaching  from  the 
base  of  the  mastoid  to  its  tip.  In  this  incision  we  do  not  meet 
the  posterior  auricular  artery,  and,  as  a  rule,  no  vessels  that  require 
ligation  are  divided.  With  the  elevator  the  soft  parts,  including 
the  periosteum,  are  separated  from  the  surface  of  the  bone,  expos- 
ing an  area  as  large  as  a  five-cent  piece  upon  a  level  with  and  just 
behind  the  external  auditory  meatus.  The  soft  parts  are  retracted 
with  broad,  sharp  retractors.  The  surface  of  bone,  which  is  thus 
laid  bare,  may  be  soft,  discolored,  and  may  further  present  the 
orifice  of  a  fistula,  or  it  may  be  firm  and  apparently  healthy  or  thick- 
ened, sclerosed,  and  ivory-like.  If  the  first  condition  exists, — that 
is,  if  the  bone  is  softened,  carious,  etc., — one  may  easily  gouge  it 
away  with  a  strong,  sharp  scoop,  continuing  thus  until  the  antrum 
is  reached.     With   the  curette  one  should   remove  all   the  bone  that 


OPERATIONS   UPON  THE  MASTOID,   ETC.  53 

is  apparently  diseased,  taking  away  enough  of  the  cortex,  especially 
down  toward  the  tip,  to  allow  good  drainage.  A  rongeur  forceps 
will  often  be  found  useful  in  thus  removing  the  cortex.  The  operator 
should  watch  for  loose  pieces  of  carious  bone.  In  working  backward 
toward  the  sigmoid  sinus  one  should  be  careful  not,  inadvertently,  to 
perforate  the  dura  and  enter  this  channel.  If  the  sinus  is  simply 
exposed,  this  is  of  no  special  significance.  There  may  be  some  hem- 
orrhage from  emissary  veins  that  pass  through  the  mastoid  foramen 
into  the  sigmoid  sinus.  Fistulse  that  are  present  should  be  carefully 
followed,  thoroughly  curetted,  and  laid  open.  They  may  lead  into  the 
auditory  canal  or  into  the  cranial  cavity.  During  the  operation  one 
should  take  frequent  soundings  with  a  blunt  probe. 

If  the  surface  of  bone  which  is  exposed  is  not  softened  and  ap- 
parently healthy  and  we  may  select  a  point  at  which  to  commence 
the  excavation  in  the  bone,  we  choose  a  point  upon  a  level  with  the 
upper  border  of  the  external  auditory  meatus  (spina  supra  meatum) 
and  from  5  to  10  mm.  behind  it.  The  antrum  is  situated  about  one- 
fourth  inch  behind  the  anterior  border  of  the  mastoid  process  upon 
a  level  with  the  upper  border  of  the  external  auditory  canal.  In 
cutting  through  the  bone  into  the  antrum  we  commence  by  using 
a  broad  chisel, — they  vary  in  width  from  2  to  8  mm., — working 
rather  with  the  corner  of  its  edge  and  chipping  the  bone  out  in  the 
form  of  a  circle  at  least  three-fourths  inch  in  diameter.  This  ex- 
cavation is  carried  deeper  into  the  substance  of  the  bone,  in  a  direc- 
tion forward,  inward,  and  downward.  As  we  progress,  narrower 
chisels  or  gouges  may  be  used  and  the  opening  made  smaller  in 
diameter.  We  continue  thus,  occasionally  sounding  with  the  probe, 
until  the  antrum  is  reached.  It  may  contain  only  a  few  drops  ot' 
pus.  During  this  part  of  the  operation  the  field  may  be  kept  clear 
of  blood  and  chips  of  bone  with  a  stream  of  salt-water  or  bichloride 
or  by  sponging.  A  funnel-shaped  excavation,  extending  through  the 
substance  of  the  mastoid,  is  thus  made,  the  base  of  the  opening  corre- 
sponding to  the  external  surface  of  the  bone  and  its  narrow  end  to 
the  antrum.  The  base,  or  external  orifice,  of  this  canal  should  be 
sufficiently  large  to  allow  of  convenient  work  in  its  deeper  part.  The 
antrum  is  usually  found  at  a  depth  of  from  12  to  20  mm.,  but  may 
occasionally  lie  nearer  the  surface.  After  having  opened  into  the  an- 
trum, if  a  probe  introduced  feels  firm,  healthy  bone,  and  if  no  sinuses 
are  present,  one  may  proceed  to  complete  the  operation  by  goug- 
ing away  the  cortex  down  to  the  tip  of  the  process  in  order  to  expose 


54  HEAD  AND  FACE. 

and  drain  these  most  dependent  cells.  It  is  also  necessary  that  the 
communication  "between  the  antrum  and  the  tympanum  is  free.  The 
drum  is  usually  already  perforated,  and  fluid  introduced  into  the 
antrum  may  escape  in  part  from  the  ear.  After  irrigating,  a  thin 
strip  of  gauze  is  packed  into  the  opening  in  the  mastoid,  reaching 
into  the  antrum,  and  the  edges  of  the  soft  parts  drawn  together 
in  part.  This  would  he  the  procedure  in  a  simple  uncomplicated 
case  of  mastoid  disease. 

In  order  to  avoid  accidental  opening  into  the  sigmoid  sinus, 
the  base,  the  commencement  of  the  cone-shaped  canal  which  is 
chiseled  through  the  bone  into  the  antrum,  is  placed  anterior  to  the 
location  of  the  sinus;  and  as  we  proceed  deeper  into  the  substance 
of  the  bone  we  work  in  a  direction  forward,  downward,  and  inward, 
so  that  there  is  no  danger  of  injuring  the  sinus,  as  it  lies  behind  the 
most  posterior  part,  base,  of  this  excavation  in  the  bone;  and  as  we 
proceed  deeper  into  the  substance  of  the  bone  we  get  farther  away 
from  the  sinus.  It  is  of  but  little  consequence  if  the  sinus  is  ex- 
posed, but  one  should  avoid  accidentally  perforating  the  dura  and 
wounding  it.  If  the  sinus  is  opened,  the  hemorrhage  which  results 
may  be  controlled  by  the  pressure  of  an  aseptic  tampon;  air  may 
be  sucked  into  the  sinus,  if  it  is  opened,  but  this  is  not  accompanied 
by  any  danger  (Schwartz).  Accidental  opening  into  the  middle 
fossa  of  the  skull  is  avoided  by  commencing  the  channel  in  the  bone 
below  the  level  of  the  upper  margin  of  the  external  auditory  meatus, 
below  the  spina  supra  meatum,  and,  as  we  proceed,  working  in  a 
direction  rather  downward.  The  floor  of  the  middle  fossa  will  thus 
lie  above  the  base  of  the  cone-shaped  canal  which  is  made  in  the 
bone. 

If  one  does  not  chisel  beyond  the  antrum,  there  is  but  little 
danger  of  injuring  the  facial  nerve  or  the  inner  wall  of  the  tym- 
panum (labyrinth).  The  facial  nerve,  contained  within  the  Fallo- 
pian tube,  lies  rather  deeper  than  the  antrum  and  anterior  to  it, 
in  the  inner  wall  of  the  tympanum.  If  one  penetrates  to  a  depth 
of  2  cm.  or  more,  there  is  then  danger  of  getting  beyond  the  antrum 
and  injuring  the  facial  nerve  or  the  labyrinth. 

For  Thrombosis  of  the  Sigmoid  Sinus. — The  sigmoid  sinus  is 
encountered  about  one-half  to  three-fourths  inch  posterior  to  the 
bony  auditory  canal  (spina  supra  meatum). 

One  should  always,  as  a  preliminary  step,  open  into  the  antrum 
as  described  above  and  from  here  start  out  to  investigate  the  sinus, 


OPERATIONS  UPON  THE  MASTOID,  ETC.  55 

etc.  After  the  antrum  has  been  opened  an  incision  is  carried  back- 
ward, through  the  soft  parts,  for  a  distance  of  about  two  inches, 
and  with  the  chisel  or  rongeur  the  bone  is  removed  in  a  direction 
backward  until  the  region  of  the  sinus  is  reached  and  the  dura  ex- 
posed. The  opening  in  the  skull  may  be  still  farther  enlarged  by 
cutting  away  its  margin  with  the  rongeur  forceps,  so  that  the  sinus 
is  freely  exposed,  and  an  opening  made  in  the  skull  which  is  suffi- 
ciently large  to  w^ork  through.  This  opening  in  the  skull  should 
be  at  least  as  large  as  a  silver  quarter.  Oftentimes  pus  and  granula- 
tion tissue  are  met  with  just  as  soon  as  the  dura  is  exposed, — extra- 
dural abscess, — and  if  the  sinus  is  not  diseased  it  will  not  be  neces- 
sary to  proceed  farther,  it  being  sufficient  to  curette  and  drain  the 
parts  about  the  sinus  without  opening  into  the  latter. 

If  the  sinus  is  thrombosed,  it  will  appear  firm  and  prominent, 
and  in  case  of  doubt  an  aseptic  aspirating  needle  may  be  introduced. 
If  pus  is  not  present  in  the  sinus  and  the  needle  withdraws  fluid 
blood  it  does  not  necessarily  prove  that  the  sinus  is  unaffected. 
Tenderness  along  the  course  of  the  internal  jugular,  etc.,  is  an  indi- 
cation for  opening  the  sinus.  If  in  doubt  it  is  always  wise  to  incise 
the  sinus,  as  this  is  not  accompanied  by  any  special  danger. 

If  one  decides  to  open  the  sinus  it  should  be  done  by  making 
an  incision,  corresponding  to  its  long  diameter,  with  a  sharp,  narrow- 
bladed  knife.  If  a  clot  is  found,  this  should  be  curetted  away  first 
from  the  jugular  end  down  to  the  bulb, — if  necessary,  removing  more 
bone  with  the  rongeur, — until  there  is  a  free  flow  of  blood:  good, 
free  bleeding  tends  to  wash  out  any  remaining  portions  of  clot.  This 
bleeding  may  be  readily  controlled  by  introducing  a  small  wad  of 
gauze  between  the  sinus  and  the  adjoining  bone.  This  flow  of  blood 
does  not  necessarily  prove  that  there  is  not  a  clot  in  the  jugular 
vein  beyond  the  bulb:  blood  may  flow  around  from  the  inferior 
petrosal  sinus. 

This  procedure  is  repeated  in  the  other  direction — i.e.,  toward 
the  torcular — until  hemorrhage  is  established;  this  may  then  be 
controlled  in  a  similar  manner.  It  may  be  well,  after  the  hemor- 
rhage has  been  controlled,  to  remove  the  packing  and  freely  irrigate 
the  sinus  with  normal  salt  solution.  Before  opening  the  sinus,  the 
internal  jugular  vein,  the  facial  vein,  etc.,  may  be  exposed  in  the 
neck  and  tied,  or  the  internal  jugular,  in  its  entirety,  and  including 
all  its  branches,  may  be  resected  through  an  incision  in  the  neck 
after  first  having  tied  the  vessel  below,  at  the  clavicle,  and  above, 


56  HEAD  AND  FACE. 

at  the  bulb  (avoid  the  pneumogastric  nerve).  This  procedure  is 
indicated  especially  if  tenderness  and  induration  are  present  along 
the  course  of  the  internal  jugular  vein :  along  the  anterior  border 
of  the  sterno-mastoid  muscle  (McKernon).  If  the  internal  jugular 
vein  has  not  been  tied,  it  may  be  compressed  in  the  neck,  during  the 
operation,  to  prevent  the  passage  of  dislodged  clots    (Dench). 

Besides  the  condition  described,  we  may  find  an  opening  lead- 
ing through  the  dura  mater  to  a  collection  of  pus  beneath  the  dura 
or  within  the  cerebellum ;  these  purulent  collections  may  also  be 
present  without  thrombosis  of  the  sinus  or  without  a  fistulous  open- 
ing in  the  dura.  All  fistulous  openings  should  be  thoroughly  explored 
and  treated  as  the  condition  indicates. 

For  Cerebellar  Abscess. — The  opening  in  the  skull  may  be  made 
with  a  trephine  or  chisel.  Usually  the  antrum  and  sinus  have  al- 
ready been  explored,  and  the  opening  in  this  case  may  be  simply 
extended  backward  with  the  rongeur.  The  center  of  the  opening 
in  the  skull  for  cerebellar  abscess  should  be  located  two  inches  behind 
the  external  auditory  meatus,  and  should  be  placed  below  a  line 
drawn  from  the  upper  margin  of  the  external  auditory  meatus  to 
the  occipital  protuberance  (see  Fig.  19).  The  opening  in  the  bone 
is  thus  placed  below  the  superior  curved  line  of  the  occipital  bone 
and  we  enter  therefore  below  the  attachment  of  the  tentorium  cere- 
belli  and  below  the  course  of  the  lateral  sinus.  The  bone  is  here 
very  thin,  and  the  opening  may  be  readily  enlarged  to  any  necessary 
extent  with  the  rongeur.  A  good  free  opening  should  be  made  in 
the  skull.  One  may  meet  pus  between  the  dura  mater  and  the  bone 
or  there  may  be  a  fistulous  opening  in  the  dura  leading  to  a  deeper 
purulent  collection.  If  there  is  no  opening  in  the  dura  an  aspirating 
needle  may  be  introduced  and  search  thus  made  for  the  pus.  When 
the  pus  is  located,  without  withdrawing  the  needle,  the  dura  may  be 
incised  and  a  director  or  thin  artery  forceps  introduced  along  the 
aspirating  needle  and  the  opening  then  enlarged  by  spreading  the 
forceps  so  as  to  permit  the  introduction  of  the  little  finger.  The 
abscess  cavity  may  be  irrigated  with  a  double-current  tube  and  then 
loosely  packed.    The  opening  in  the  dura  may  be  closed  in  part. 

For  Extradural  Abscess  in  the  Middle  Fossa. — There  may  be  an 
abscess  located  between  the  dura  mater  and  the  bone. 

If  the  mastoid  antrum  has  already  been  explored  one  may  find 
a  fistula  leading  through  the  roof  of  the  antrum  or  tympanum  into 
the  middle  fossa.    The  incision,  which  is  already  present  and  through 


SURGICAL  ANATOMY  OF  THE  FACE.  57 

which  the  mastoid  antrum  has  been  opened,  is  prolonged  from  the 
base  of  the  mastoid  in  a  direction  upward  and  forward  over  the  ear, 
dividing  the  temporal  vessels  and  muscle.  With  the  rongeur  or 
chisel,  the  bone  is  cut  away  so  that  one  may  enter  the  middle  fossa 
just  above  and  in  front  of  the  external  auditory  meatus;  here  we 
work  in  between  the  tegmen  tympani  and  the  dura  mater,  where 
the  abscess  is  usually  located.  The  pus  is  evacuated  and  the  abscess 
cavity  drained  as  described  in  the  preceding  operation. 

For  Temporo-sphenoidal  Abscess.  —  Associated  with  the  extra- 
dural abscess  we  may  find  an  abscess  in  the  temporo-sphenoidal  lobe, 
and  there  may  be  a  fistula  leading  through  the  dura  and  commu- 
nicating with  such  a  collection.  In  this  case  the  fistula  should  be 
followed,  enlarging  the  opening  in  the  dura,  evacuating  and  draining 
the  abscess.  A  temporo-sphenoidal  abscess  may  be  present  without 
an  extradural  abscess. 

If  the  mastoid  has  been  already  explored,  one  may  extend  the 
incision  upward  and  forward  over  the  ear,  as  described  in  the  pre- 
ceding operation,  and  remove  sufficient  bone  with  the  chisel  and 
rongeur,  proceeding  from  the  opening  in  the  mastoid,  or,  instead 
of  this,  a  button  of  bone  may  be  removed  with  the  trephine.  This 
opening  in  the  skull  should  be  at  least  one  inch  in  diameter  with 
its  center  located  one  and  one-fourth  inches  above  the  bony  meatus, 
and  may  be  farther  enlarged  with  the  rongeur  forceps  to  the  requisite 
dimensions  (see  Fig.  19). 

The  temporo-sphenoidal  lobe  may  also  be  exposed  by  doing 
a  temporary  resection  of  the  skull  (see  "Ligation  of  the  Middle 
Meningeal  Artery"). 

After  the  dura  has  been  exposed  an  aspirator  is  introduced,  and 
when  pus  is  discovered  the  dura  is  incised  and,  without  withdrawing 
the  needle,  a  director — or,  better,  an  artery  forceps — is  introduced 
and  the  abscess  freely  opened  by  spreading  the  forceps  and  with- 
drawing them.  The  finger  may  be  then  introduced  and  the  abscess 
cavity  irrigated  with  a  double-current  tube  and  packed.  The  open- 
ing in  the  dura  may  be  partly  closed. 

THE  FACE. 

Surgical  Anatomy  of  the  Face. — The  skin  of  the  face  is  soft, 
thin,  and  intimately  united  to  the  underlying  muscles  and  connective 
tissue,  and  cannot  be  pinched  up  without  including  these  deeper 


58  HEAD  AND  FACE. 

layers.  The  subcutaneous  tissue  of  the  face  is  widely  meshed,  and 
within  these  meshes  there  is  contained  much  fat.  Those  parts  of 
the  face  where  the  fat  is  absent  from  the  subcutaneous  layer  are 
loose  and  flaccid, — for  example,  under  the  eyes, — and  become  marked 
early  in  life  by  wrinkles.  These  parts  also  readily  become  swollen 
and  distended  in  dropsical  conditions.  In  this  layer  are  contained 
the  muscles  of  expression  and  the  vessels  and  nerves. 

The  facial  artery  is  the  chief  source  of  supply  to  the  face.  It 
is  a  large  vessel  derived  from  the  external  carotid.  It  pursues  a 
tortuous  course,  upward  and  forward,  across  the  side  of  the  face, 
from  the  anterior  border  of  the  masseter  to  the  angle  of  the  mouth, 
and  then,  as  the  angular,  continues  upward  alongside  the  nose,  anas- 
tomosing at  the  inner  canthus  with  a  branch  of  the  ophthalmic. 
Just  below  1  he  corner  of  the  mouth  the  facial  gives  off  a  branch,  the 
inferior  labial,  for  the  supply  of  the  lower  lip;  those  from  either 
side  anastomose.  At  the  corner  of  the  mouth  the  facial  gives  off 
the  inferior  and  superior  coronary.  These  branches  pass  inward, 
lying  a  little  beyond  the  edge  of  either  lip  and  situated  beneath 
the  mucous  membrane:  between  it  and  the  muscular  structure  of 
the  lip.    Those  from  either  side  anastomose  freely  with  their  fellows. 

The  facial  vein,  which  accompanies  the  artery,  is  not  tortuous, 
and  lies  superficial  to  the  artery. 

The  facial  nerve  supplies  the  muscles  of  expression,  etc.,  and 
the  buccinator.  It  emerges  from  the  parotid  gland  upon  the  side 
of  the  face  at  a  point  corresponding  to  the  lower  border  of  the  lobe 
of  the  ear,  and  divides  into  branches  which  supply  the  facial  mus- 
cles and  the  platysma.  The  sensory  supply  to  the  face  and  teeth 
is  derived  from  the  fifth  nerve. 

The  Skeleton  of  the  Face. — The  upper  part  consists  of  the 
superior  maxillary  and  the  adjoining  bones  with  which  it  articulates 
and  which  serve  to  join  it  to  the  skull;  it  articulates,  toward  the 
middle  line,  with  the  nasal  bones  which  form  the  bridge  of  the  nose 
and  laterally  with  the  malar.  The  malar  bone  forms  the  prominent 
part  of  the  cheek  and  gives  off  a  process  which  passes  backward  and 
unites  with  a  similar  process  from  the  temporal  to  form  the  zygo- 
matic arch. 

The  body  of  the  superior  maxillary  is  pyramidal,  its  base  being 
directed  inward  toward  the  nasal  cavity,  forming  part  of  its  outer 
wall  and  presenting  the  opening  into  the  antrum  of  Highmore;  its 
apex  corresponds  to  its  junction  with  the  malar.     The  upper  surface 


SURGICAL  ANATOMY  OF  THE  FACE.  59 

of  the  superior  maxillary  is  thin  and  forms  the  floor  of  the  orbit.  Its 
anterior  or  facial  surface  is  very  thin  in  places  and  easily  perforated;  it 
is  rather  concave,  and  just  below  the  margin  of  the  orbit  presents  the 
opening  of  the  infra-orbital  canal.  A  canal  descends,  as  an  offshoot 
from  the  infra-orbital  canal,  through  the  anterior  wall  of  the  bone;  it 
transmits  a  nerve-branch  which  supplies  the  upper  front  teeth.  The 
posterior,  or  zygomatic,  surface  of  the  superior  maxilla  looks  backward 
and  outward  toward  the  zygomatic  fossa;  it  gives  origin,  in  part,  to  the 
external  pterygoid  muscle,  and  is  in  close  relation  with  the  termina- 
tion of  the  internal  maxillary  artery.  This  surface  presents  the 
commencement  of  the  superior  dental  canal  for  the  transmission  of 
the  superior  dental  nerve  to  the  upper  back  teeth. 

The  body  of  the  bone  is  hollowed  out.  The  space  within,  known 
as  the  antrum  of  Highmore,  communicates  with  the  nasal  cavity 
through  an  opening  into  the  middle  meatus,  and  is  lined  with  mu- 
cous membrane,  which  is  continuous  with  that  of  the  nose.  The 
walls  inclosing  the  antrum  are  thin,  but  strengthened  by  columns 
of  bone  which  ascend  from  the  tooth  sockets  and  converge  toward 
the  apex,  malar  process;  in  this  way  the  bone  is  strengthened  and 
the  shock  of  blows  distributed.  The  alveolar  process  is  solid  and 
presents  the  sockets  for  the  teeth.  The  palate  process,  projecting 
inward,  joins  with  its  fellow  of  the  opposite  side,  and  together  with 
the  horizontal  plates  of  the  palate  bones  forms  the  hard  palate:  the 
floor  of  the  nasal,  and  the  roof  of  the  buccal,  cavity. 

The  periosteum  covering  the  upper  jaw  is  thin  and  closely  at- 
tached to  the  surface  of  the  bone.  It  is  rather  more  easily  separated 
from  the  orbital  and  facial  surfaces. 

The  lower  part  of  the  face  is  composed  of  the  inferior  maxillary, 
which  consists  of  a  body  and  two  rami  and  which  is  attached  to  the 
skull  through  the  temporo-maxillary  articulations.  The  body  of  the 
bone  is  horseshoe-shaped,  presenting  an  upper  border,  with  sockets 
for  the  teeth,  and  a  lower  rounded  border,  which  may  be  felt  beneath 
the  integument. 

To  the  inner  surface  of  the  body  of  the  inferior  maxillary  are 
attached  the  muscles  which  form  the  floor  of  the  mouth,  and  in 
front,  at  the  symphysis,  are  attached  the  muscles  which  draw  the 
tongue  forward  and  prevent  its  dropping  back  into  the  pharynx. 

The  ramus  is  a  perpendicular  plate  of  bone  with  an  upper 
curved  border  which  presents,  in  front,  a  thin,  pointed  process,  the 
coracoid,  to  which  is  attached  the  tendon  of  the  temporal  muscle, 


60  '  HEAD  AND  FACE. 

and,  behind,  a  rather  thickened  process,  the  condyle.  The  upper 
surface  of  the  condyle  is  rounded  and  smooth,  for  articulation  with 
the  glenoid  cavity.  Below  the  articular  surface  there  is  a  rather 
constricted  portion,  known  as  the  neck.  To  the  front  surface  of 
the  neck  of  the  condyle  is  attached  the  tendon  of  the  external 
pterygoid  muscle.  The  lower  posterior  corner  of  the  ramus  is  a 
prominent  landmark,  and  is  called  the  angle  of  the  jaw.  The  outer 
surface  of  the  ramus  is  covered  by  the  masseter  and  gives  attach- 
ment to  this  muscle.  The  inner  surface  of  the  ramus  presents, 
about  its  middle,  the  orifice  of  the  inferior  dental  canal,  into  which 
the  nerve  of  the  same  name  passes  to  supply  the  teeth  of  the  lower 
jaw.  The  anterior  margin  of  this  orifice  is  marked  by  a  small  pointed 
process  of  bone,  to  which  the  long  internal  lateral  ligament  is  at- 
tached. The  internal  pterygoid  muscle  is  attached  to  the  lower 
posterior  part  of  the  inner  surface. 

Sixteen  teeth  are  inserted  in  each  jaw,  eight  on  a  side:  two 
incisors  nearest  the  middle  line,  and,  following  these,  one  canine, 
two  bicuspids,  and  three  molars. 

The  Mouth. — The  mouth  is  inclosed  by  the  lips  and  cheeks. 

The  lips  are  composed  of  fatty  connective  tissue  and  muscular 
tissue,  and  are  covered  externally  by  the  skin  and  internally  by 
the  mucous  membrane.  The  muscular  fibers  are  found  in  the  sub- 
cutaneous connective-tissue  layer,  coming  from  all  directions  and 
interlacing  with  each  other,  and  with  much  fatty  tissue  interspersed 
between  them.  The  mucous  membrane,  lining  the  inner  surface  of 
the  lips,  is  continued  over  upon  the  gums.  In  the  middle  line,  from 
the  lip  to  the  gum,  there  is  a  thin,  delicate  fold  of  mucous  mem- 
brane, the  framum,  which  is  well  seen  when  the  lip  is  drawn  away 
from  the  gum.  The  vessels  to  the  lips  are  the  labial  and  the  in- 
ferior coronary  to  the  lower  lip,  and  the  superior  coronary  to  the 
upper  lip.     These  branches  are  derived  from  the  facial. 

The  cheeks  are  formed  of  skin,  connective  tissue  and  fat,  buc- 
cinator muscle,  and  mucous  membrane.  The  buccinator  muscle  is 
attached  to  the  outer  surface  of  the  upper  and  lower  jaw-bones  just 
beyond  the  alveolar  processes.  This  muscle  is  covered,  upon  its 
external  surface,  by  a  layer  of  fascia,  bucco-pharyngeal,  which  is  con- 
tinuous behind  with  that  covering  the  constrictors  of  the  pharynx. 
The  mucous  membrane  lining  the  inner  surface  of  the  cheeks  is 
continuous  with  that  of  the  gums.  The  buccal  cavity  may  be  divided 
into  an  outer  space,  the  vestibule,  and  an  inner  space,  the  mouth 


SURGICAL  ANATOMY  OF  THE  FACE.  qj_ 

proper.  The  vestibule  is  the  space  between  the  teeth  and  the  cheeks 
and  lips.  When  the  mouth  is  closed  the  mucous  membrane  lining 
the  cheeks  is  thrown  into  folds,  which  would  be  caught  between  the 
teeth  if  not  prevented  by  the  contraction  of  the  buccinator  to  which 
the  mucous  membrane  is  firmly  attached. 

Opposite  the  second  upper  molar  tooth  is  the  orifice  of  Stenson's 
duct.  At  times  this  orifice  is  marked  by  a  papilla,  which  may  assist 
one  in  locating  it. 

The  mucous  membrane,  from  the  lips  and  cheeks,  is  reflected 
upon  the  alveolar  process  of  the  upper  and  lower  jaw  and  extends 
between  the  teeth.  It  is  intimately  united  with  the  periosteum  cov- 
ering the  bone,  and  together  with  it  forms  the  gums.  Behind  the 
last  molar  tooth  the  anterior  border  of  the  ramus  of  the  jaw  may 
be  felt,  and  upon  the  outer  side  of  this  the  masseter  muscle  may 
also,  when  contracted,  be  distinctly  recognized.  When  the  teeth  are 
tightly  closed,  the  vestibule  communicates  with  the  cavity  of  the 
mouth  proper  by  a  small  space  behind  the  last  molar  tooth  upon 
either  side. 

The  cavity  of  the  mouth  proper  presents  a  roof  and  a  floor,  and 
is  bounded  in  front  and  upon  the  sides  by  the  alveolar  processes  and 
the  teeth.  Behind,  the  mouth  opens  into  the  pharynx.  It  is  sepa- 
rated from  the  larynx  by  the  epiglottis,  and  from  the  posterior  nasal 
space  by  the  soft  palate.  Where  the  cavity  of  the  mouth  opens  into 
the  pharynx  it  is  somewhat  narrowed  and  is  called  the  isthmus  of 
the  fauces.  The  isthmus  is  bounded  above  by  the  free  edge  of  the 
soft  palate;  below,  by  the  tongue;  and,  upon  the  sides,  by  the  pillars 
of  the  fauces. 

The  roof  of  the  mouth  is  divided  into  the  hard  and  soft  palate. 
The  hard  palate  is  formed  by  the  junction,  in  the  middle  line,  of 
the  palatal  processes  of  the  superior  maxillaries  in  front,  and  of  the 
horizontal  plates  of  the  palate  bones,  behind.  It  is  concave,  and 
arched  from  side  to  side  and  from  before  backward.  In  front,  in 
the  middle  line,  just  behind  the  incisor  teeth,  is  a  foramen,  the 
orifice  of  the  -anterior  palatine  canal,  which  transmits  the  anterior 
palatine  vessels.  Extending  from  this  foramen,  forward  and  out- 
ward, to  a  point  between  the  lateral  incisors  and  the  canine  teeth, 
on  either  side,  may  be  seen,  occasionally,  a  line  which  marks  the 
junction  of  the  intermaxillary  bone  with  the  palatal  processes  of 
the  superior  maxillaries. 

Near  the  posterior  edge  of  the  hard  palate,  just  to  the  inner 


62  HEAD  AND  FACE. 

side  of  the  last  molar  tooth,  is  the  orifice  of  the  posterior  palatine 
canal,  and  passing  forward  from  this  is  a  groove,  close  to  the  alveolar 
process.  The  posterior  palatine  vessels  descend  through  the  poste- 
rior palatine  canal  and  then  pass  forward,  upon  the  hard  palate, 
lying  in  the  groove  just  mentioned.  Behind  the  orifice  of  the  poste- 
rior palatine  canal  may  be  seen  the  hook-like  hamular  process:  the 
termination  of  the  internal  pterygoid  process,  around  which  the 
tendon  of  the  tensor  palati  is  reflected  before  it  spreads  out  in  the 
soft  palate.  The  mucous  membrane  and  periosteum,  which  cover 
the  hard  palate,  are  intimately  united  with  each  other  and  to  the 
surface  of  the  bone.  There  is  little  or  no  anastomosis  between  the 
vessels  across  the  middle  line;  so  that  in  operating  for  cleft  palate 
it  is  desirable  to  retain  the  arteries  in  the  flaps  (Langenbeck). 

The  soft  palate  is  a  curtain-like  structure  suspended  from  the 
posterior  border  of  the  hard  palate.  It  is  composed  of  the  spread- 
out  aponeuroses  of  the  tensor  and  levator  palati.  It  marks  the 
boundary  line  between  the  mouth  and  the  pharynx.  It  presents  an 
inferior,  or  anterior,  and  a  superior,  or  posterior,  surface,  each  cov- 
ered with  mucous  membrane. 

The  lower,  or  free,  border  of  the  soft  palate  presents,  in  the 
middle  line,  the  uvula  and  upon  either  side  separates  into  the  ante- 
rior and  posterior  pillars  of  the  fauces.  The  anterior  pillar  is  con- 
tinued downward  into  the  side  of  the  base  of  the  tongue  at  a  point 
just  behind  the  last  molar  tooth  of  the  lower  jaw,  and  is  made  up 
of  the  palato-glossus  muscle.  The  posterior  pillar  is  continued 
downward  and  backward  into  the  side  of  the  pharynx,  and  is  com- 
posed of  the  palato-pharyngeus  muscle.  Between  the  two  pillars  of 
the  fauces  there  is  a  triangular  space  in  which  the  tonsil  is  lodged. 
Just  above  the  soft  palate,  in  the  side  of  the  pharynx,  is  the  orifice 
of  the  Eustachian  tube;  it  is  about  on  a  level  with  the  floor  of  the 
nose. 

In  quiet  breathing  the  soft  palate  hangs  passive;  but  during 
the  act  of  swallowing  it  becomes  tense,  owing  to  the  contraction  of 
its  muscles,  and  its  free  border  then  comes  into  contact  with  the 
posterior  wall  of  the  pharynx,  thus  shutting  off  the  posterior  nasal 
space  from  the  cavity  of  the  mouth. 

The  floor  of  the  mouth  is  formed  of  soft  parts:  chiefly  by  the 
mylo-hyoid  muscle.  This  muscle  extends  from  the  mylo-hyoid 
ridge,  upon  the  inner  surface  of  the  body  of  the  inferior  maxilla,  to 
the  body  and  greater  cornu  of  the  hyoid  bone,  uniting  with  its  fellow 


SURGICAL  ANATOMY  OF  THE  FACE.  (53 

in  the  middle  line.  The  upper  surface  of  the  muscle,  which  is 
directed  toward  the  cavity  of  the  mouth,  is  covered  over  by  the 
mucous  membrane,  beneath  which  are  found,  on  either  side,  the 
sublingual  gland,  Wharton's  duct,  the  gustatory  nerve,  etc.  *  The 
external  surface  of  the  mylo-hyoid  muscle  forms  part  of  the  floor 
of  the  submaxillary  triangle,  and  is  in  relation  with  the  submaxillary 
gland. 

The  tongue  is  a  muscular  organ  which  projects  upward  and 
forward  from  the  floor  of  the  mouth.  It  is  attached  by  its  base 
and  through  several  muscles  to  the  hyoid  bone,  and  is  connected 
with  the  epiglottis  through  the  glosso-epiglottidean  folds  of  mucous 
membrane.  The  tongue  is  composed  of  a  mass  of  muscular  and 
connective  tissue  interspersed  with  much  fat,  and  is  partly  divided 
into  two  symmetrical  halves  by  a  fibrous  septum.  The  tongue  is 
connected  with  the  hyoid  bone  by  the  hyo-glossus  muscle  on  each 
side;  with  the  styloid  process  by  the  stylo-glossus;  with  the  soft 
palate  by  the  palato-glossus,  and  through  the  genio-hyo-glossus  with 
the  symphysis  of  the  lower  jaw-bone — this  muscle  serves  to  draw 
the  tongue  forward  and  prevents  its  dropping  back  into  the  pharynx 
and  obstructing  breathing. 

When  the  mouth  is  closed  its  cavity  is  almost  completely  occu- 
pied by  the  tongue.  The  anterior  part  of  the  upper  surface  of  the 
tongue  is  in  contact  with  the  hard  palate;  the  posterior  part,  with 
the  soft  palate  and  the  epiglottis.  The  tongue  is  covered  by  mucous 
membrane,  that  covering  the  under  surface  and  sides  of  the  organ 
being  similar  to  that  of  the  rest  of  the  mouth.  That  covering  its 
upper  surface,  dorsum,  is  rough,  marked  by  numerous  glands,  and 
composed  of  a  thick  layer  of  flat  epithelium,  which  gives  it  rather 
a  grayish  color.  If  the  tongue  is  lifted  away  from  the  floor  of  the 
mouth  by  its  tip,  the  attachment  of  its  under  surface  to  the  floor 
of  the  mouth,  in  the  middle  line,  through  a  membranous  band,  the 
frsenum  linguae,  is  seen. 

The  sublingual  glands  consist  each  of  a  number  of  lobules,  and 
are  located  in  the  front  part  of  the  mouth,  upon  either  side  of  the 
frsenum,  resting  upon  the  mylo-hyoid  muscle  and  covered  over  by 
the  mucous  membrane.  The  location  of  the  glands  is  indicated  by 
a  slight  swelling  in  the  floor  of  the  mouth,  which  presents  the  little 
pin-point  orifices  of  their  excretory  ducts. 

Upon  either  side  of  the  frsenum  there  is  a  little  papilla  showing 
the  orifice  of  Wharton's  duct.     This  is  the  excretory  duct  of  the 


64  HEAD  AND  FACE. 

submaxillary  gland;  it  passes  forward,  through  the  floor  of  the 
mouth,  lying  below  and  to  the  inner  side  of  the  sublingual  gland. 

Each  half  of  the  tongue  is  supplied  by  the  corresponding  lingual 
artery;  this  is  a  large  branch  which  is  given  off  from  the  external 
carotid  just  above  the  greater  cornu  of  the  hyoid  bone.  It  passes  for- 
ward beneath  the  hyo-glossus  muscle,  and  ascends  beneath  this  mus- 
cle to  the  under  surface  of  the  tongue,  where  it  is  continued  forward 
to  its  tip.  The  chief  vein  of  the  tongue  is  the  ranine,  a  large  branch, 
which  passes  backward  upon  the  outer  surface  of  the  hyo-glossus 
muscle  and  terminates  in  the  internal  jugular. 

The  nerves  to  the  tongue  are  the  hypoglossal,  the  gustatory, 
and  the  glosso-pharyngeal.  The  hypoglossal  descends  in  the  neck 
as  far  as  the  point  where  the  occipital  artery  is  given  off  from  the 
external  carotid;  here  it  passes  forward,  above  and  parallel  with 
the  greater  cornu  of  the  hyoid  bone,  resting  upon  the  hyo-glossus 
muscle.  The  gustatory  is  one  of  the  branches  derived  from  the  third 
division  of  the  fifth  nerve.  From  its  origin  it  descends  in  front  of 
the  inferior  maxillary  nerve,  lying  between  the  internal  pteiwgoid 
muscle  and  the  ramus  of  the  jaw;  here  it  communicates  with  the 
chorda  tympani,  from  the  facial,  and  passing  forward,  beneath  the 
body  of  the  jaw  and  above  the  submaxillary  gland,  gives  off  its 
branches  to  the  submaxillary  ganglion;  continued  forward,  upon  the 
hyo-glossus  muscle,  it  crosses  Wharton's  duct,  and  is  continued 
alongside  the  tongue  to  its  apex,  lying  directly  beneath  the  mucous 
membrane.  The  glosso-pharyngeal  is  of  but  little  surgical  impor- 
tance. It  descends  in  the  neck,  in  front  of  the  internal  jugular  vein 
and  the  internal  carotid  artery,  curving  forward  upon  the  outer  side 
of  the  stylo-pharyngeus  muscle,  to  be  distributed  to  the  base  of  the 
tongue,  etc. 

The  Side  of  the  Face. — Passing  transversely  from  behind  for- 
ward beneath  the  integument,  the  zygomatic  arch  may  be  felt.  This 
bony  arch  is  formed  by  the  junction  of  the  zygomatic  process  of  the 
temporal  with  that  of  the  malar.  It  is  a  prominent  landmark,  and 
serves  to  separate  the  side  of  the  head,  the  temporal  region,  from 
the  side  of  the  face,  the  pterygo-maxillary  region. 

The  Pterygo-maxillary  Eegion  corresponds  to  that  part  of 
the  side  of  the  face  which  is  situated  below  the  level  of  the  zygoma. 

The  skin  of  this  region  is  intimately  connected  with  the  under- 
lying subcutaneous  connective  tissue,  which  is  thick  and  only  loosely 
attached  to  the  fascia  covering  the  masseter  muscle. 


SIDE  OF  THE  FACE.  65 

The  masseter  muscle  is  a  strong,  thick  muscle  arising  by  two 
portions  from  the  lower  border  and  inner  surface  of  the  zygoma.  Its 
fibers  pass  downward,  covering  the  ramus  of  the  jaw,  to  the  outer 
surface  of  which  and  to  the  angle  of  the  jaw  it  is  attached.  It  is 
covered  by  an  expansion  of  the  cervical  fascia,  which  is  attached 
above  to  the  lower  border  of  the  zygoma.  The  facial  artery  crosses 
the  lower  border  of  the  inferior  maxilla  just  in  front  of  the  masse- 
ter  muscle,  grooving  the  bone  in  this  situation  and  passing  upward 
and  forward  across  the  cheek  to  the  side  of  the  nose.  It  is  accom- 
panied by  the  facial  vein,  which  joins  with  a  branch  from  the  tem- 
poro-maxillary  and  thus  constitutes  a  big  branch,  the  temporo-facial, 
which  terminates  in  the  internal  jugular. 

After  the  skin  and  subcutaneous  fat  have  been  removed  in  this 
region  the  parotid  gland  is  exposed.  This  gland  is  situated  upon  the 
side  of  the  face,  reaching  from  the  zygoma,  above,  to  below  the  angle 
of  the  jaw.  It  lies  in  the  space  bounded  by  the  angle  of  the  jaw  and 
the  posterior  border  of  the  ramus  in  front,  and  the  mastoid  process 
behind,  and  extends  forward  upon  the  side  of  the  face,  lying  upon 
the  back  part  of  the  masseter  muscle.  The  parotid  gland  is  covered 
by  a  strong  layer  of  fascia,  which  forms  a  sort  of  fibrous  envelope 
and  sends  prolongations  into  the  gland  to  support  it.  This  fascia  is 
continued  forward  on  to  the  masseter  and  buccinator  muscles,  and 
downward  upon  the  side  of  the  neck,  where  it  is  continuous  with 
the  cervical  fascia.  It  is  also  attached  to  the  angle  of  the  jaw.  The 
duct  of  Stenson  (duct  of  the  parotid  gland)  is  about  two  inches  long 
and  lies  about  a  finger's  breadth  below  the  zygoma,  passing  forward 
across  the  masseter,  at  the  anterior  border  of  which  it  pierces  the 
cheek  to  enter  the  mouth  opposite  the  second  molar  tooth  of  the 
upper  jaw. 

The  facial  nerve,  after  emerging  from  the  styloid  foramen, 
passes  forward  and  downward  into  the  substance  of  the  parotid 
gland.  It  crosses  the  external  carotid  artery  and  divides  in  the 
substance  of  the  parotid  gland  into  several  branches,  which  form 
the  pes  anserinus  and  which  are  distributed  upon  the  side  of  the 
face  to  supply  the  muscles,  etc. 

The  auriculo-temporal  nerve  emerges  upon  the  face  behind  the 
neck  of  the  condyle  of  the  jaw  after  passing  through  the  upper  part 
of  the  parotid  gland.  It  ascends  across  the  root  of  the  zygoma,  in 
front  of  the  ear,  in  company  with  the  temporal  artery,  to  be  dis- 
tributed upon  the  side  of  the  head  (temporal  region). 


qq  HEAD  AND  FACE. 

Beneath  the  parotid  gland  or  within  its  substance  the  external 
carotid  artery  divides  into  its  terminal  branches:  the  internal  maxil- 
lary and  the  temporal.  The  temporal  ascends  through  the  substance 
of  the  gland  and  across  the  root  of  the  zygoma,  just  in  front  of  the 
cartilage  of  the  ear,  the  auriculotemporal  nerve  lying  posterior  to 
it;  and  about  two  inches  above  the  zygoma  it  divides  into  the  ante- 
rior and  posterior  temporal.  These  branches,  lodged  in  the  subcu- 
taneous connective-tissue  layer  of  the  temporal  region,  divide  and 
supply  this  part  of  the  scalp,  anastomosing  anteriorly  with  branches 
from  the  frontal  and  posteriorly  with  the  occipital,  etc.  The  inter- 
nal maxillary  artery  is  not  exposed  until  after  the  removal  of  the 
ramus  of  the  jaw,  etc.  (see  later).  The  temporal  artery  is  accom- 
panied by  the  temporal  vein.  The  temporal  vein  does  not  lie  within 
the  substance  of  the  parotid  gland,  but  superficial  to  it;  it  receives 
many  tributaries,  and  below  the  angle  of  the  jaw  divides  into  two 
branches;  the  posterior  joins  with  the  posterior  auricular  to  form 
the  external  jugular  vein;  the  anterior  joins  with  the  facial  to  form 
a  large  branch,  the  temporo-facial,  which  passes  obliquely  backward 
across  the  upper  part  of  the  superior  carotid  triangle,  to  enter  the  in- 
ternal jugular.  This  branch  is  often  cut  in  extirpating  glands,  etc., 
in  this  part  of  the  neck,  and  may  give  rise  to  profuse  hemorrhage. 

The  deeper  parts  of  this  region  are  exposed  by  dividing  the 
zygomatic  arch  with  the  chisel  or  chain-saw  at  its  anterior  and  poste- 
rior extremities,  and  then,  after  cutting  the  attachment  of  the  tem- 
poral fascia  from  its  upper  border,  turning  the  detached  segment  of 
the  arch,  with  the  attached  masseter,  downward.  There  is  then 
exposed  the  upper  part  of  the  ramus  of  the  jaw,  with  its  coracoid 
process,  to  which  the  tendon  of  the  temporal  is  attached.  This 
process  is  now  cut  away  from  the  ramus,  and,  together  with  the 
attached  tendon  of  the  temporal,  turned  upward,  and  we  then  have 
exposed  to  view  the  pterygo-maxillary  region  proper.  Occupying 
this  space  is  the  external  pterygoid  muscle.  This  muscle  arises,  by 
its  broad  anterior  end,  from  the  under  surface  of  the  great  wing  of 
the  sphenoid  and  from  the  outer  surface  of  the  external  pterygoid 
plate;  behind,  its  narrow  end  is  attached  to  a  depression  in  the 
anterior  surface  of  the  neck  of  the  condyle  of  the  lower  jaw  and  to 
the  anterior  margin  of  the  interarticular  fibrocartilage  of  the  tem- 
poro-maxillary  joint.  Curving  around  its  lower  border  and  passing 
forward  and  upward  upon  its  outer  surface  may  be  seen  the  internal 
maxillary  artery.     This  vessel  gives  off  branches  to  the  adjoining 


SIDE  OF  THE  FACE.  67 

muscles  and  disappears,  anteriorly,  by  passing  into  the  spheno- 
maxillary fossa  between  the  two  heads  of  the  external  pterygoid 
muscle.  This  vessel  may  now  be  cut  away  and  the  muscle  cut  short 
at  its  attachment  to  the  condyle  of  the  jaw  and  also  close  to  its 
origin,  and  in  this  way  the  parts  which  lie  beneath  the  external 


Fig  20.— Pterygo-maxillary  Region.  Ramus  of  the  jaw  and  the  zygomatic 
arch  cut  away.  IB,  inferior  dental  nerve;  IAI,  internal  maxillary  artery; 
L,  lingual,  or  gustatory,  nerve;  PE,  external  pterygoid  muscle;  PI,  internal 
pterygoid  muscle;  SM,  superior  maxillary  (second  division  of  fifth)  nerve 
crossing  the  spheno-maxillary  fossa  from  behind  forward. 


pterygoid  muscle  are  exposed, — the  zygomatic  and  spheno-maxillary 
fossa?,  with  their  important  vascular  and  nervous  structures. 

The  zygomatic  fossa  is  that  space  which  is  limited  above  by 
the  prominent  horizontal  ridge  called  the  pterygoid  ridge  which  is 
found  upon  the  under  surface  of  the  great  wing  of  the  sphenoid 


68 


HEAD  AND  FACE. 


about  opposite  the  zygoma.  The  floor  of  the  zygomatic  fossa  is  com- 
posed of  the  under  surface  of  the  great  wing  of  the  sphenoid  (base 
of  the  skull)  from  the  pterygoid  ridge  to  the  base  of  the  pterygoid 
process,  and  also  of  the  surface  of  the  external  plate  of  the  pterygoid 
process.    It  presents  the  foramen  ovale  and  the  foramen  spinosum. 


Fig.  21. — Pterygo-maxillary  Region.  External  pterygoid  muscle  cut  away, 
exposing  external  pterygoid  plate,  etc.  AT,  auriculotemporal  nerve;  ID, 
inferior  dental  nerve;  IM,  internal  maxillary  artery;  L,  lingual,  or  gustatory, 
nerve;  MM,  middle  meningeal  artery;  PI,  internal  pterygoid  muscle;  8M, 
superior  maxillary  (second  division  of  the  fifth)  nerve  passing  across  the 
spheno-maxillary  fossa. 

The  spheno-maxillary  fossa  is  the  narrow  perpendicular  space 
which  is  bounded  in  front  by  the  posterior  aspect  of  the  superior 
maxilla  and  behind  by  the  front  of  the  pterygoid  process.  Its  inner 
wall  is  formed  by  the  vertical  plate  of  the  palate  bone  and  consti- 
tutes a  part  of  the  lateral  wall  of  the  nasal  cavity.    Above,  this  space 


SIDE  OF  THE  FACE.  69 

is  bounded  by  the  orbital  process  of  the  palate  bone  and  the  body 
of  the  sphenoid.  The  inner  wall  presents,  above,  the  spheno-palatine 
foramen,  through  which  it  communicates  with  the  nasal  cavity  and 
below  the  upper  opening  or  commencement  of  the  posterior  palatine 
canal.  Into  the  upper  part  of  this  fossa,  upon  its  posterior  wall, 
the  foramen  rotundum  opens;  above  and  internal  to  this  is  the 
opening  of  the  Vidian  canal.  The  anterior  wall  of  this  space  pre- 
sents the  commencement  of  the  infra-orbital  canal. 

Located  between  the  inner  surface  of  the  condyle  of  the  lower 
jaw  and  the  internal  lateral  ligament  is  the  first  part  of  the  internal 
maxillary  artery;  in  this  situation  the  vessel  gives  off  the  middle 
meningeal  branch,  which  passes  directly  upward  and  enters  the  skull 
through  the  foramen  spinosum.  The  middle  meningeal  artery,  at 
its  origin,  is  surrounded  by  the  two  roots  of  the  auriculo-temporal 
nerve;  these  two  roots  join  posteriorly  to  form  the  auriculo-tem- 
poral, which  passes  backward,  as  far  as  the  temporal  artery,  and, 
after  emerging  from  the  upper  part  of  the  parotid  gland,  ascends  in 
front  of  the  ear,  to  be  distributed  to  the  integument  of  the  temporal 
region. 

A  little  in  front  and  to  the  inner  side  of  the  middle  meningeal 
artery  may  be  observed  the  inferior  maxillary  division  of  the  fifth 
nerve.  This  trunk  consists  of  a  large  sensory  root  and  a  smaller 
motor  root,  which  emerge  from  the  skull  through  the  foramen  ovale 
and  join  together  outside  this  opening,  just  below  the  base  of  the 
skull,  to  form  the  inferior  maxillary  division. 

The  inferior  maxillary  division  gives  off  two  temporal  branches, 
which  pass  upward  beneath  the  temporal  muscle,  and  two  large 
branches,  which  pass  downward  and  forward.  One  of  these,  the 
lingual  or  gustatory,  is  joined  below  by  the  chorda  tympani,  a  branch 
of  the  facial,  and  the  other,  the  inferior  dental,  enters  the  canal  on 
the  inner  surface  of  the  ramus  of  the  jaw  to  supply  the  lower  teeth. 
Attached  to  the  inner  posterior  aspect  of  the  inferior  maxillary 
division  is  the  otic  ganglion;  it  is  located  just  below  the  foramen 
ovale. 

In  the  upper  part  of  the  spheno-maxillary  fossa  is  seen  the 
middle,  or  superior  maxillary,  division  of  the  fifth  nerve.  This 
nerve  leaves  the  skull  through  the  foramen  rotundum,  passes  for- 
ward, across  the  upper  part  of  the  spheno-maxillary  fossa  and,  as 
the  infra-orbital,  and  accompanied  by  the  terminal  branch  of  the 
internal  maxillary  artery,  enters  the  infra-orbital  canal,  and  is  finally 


70  HEAD  AND  FACE. 

distributed  to  the  skin  of  the  front  of  the  face,  below  the  orbit. 
Suspended  from  the  lower  border  of  the  middle  division,  as  it  passes 
across  the  upper  part  of  the  spheno-maxillary  space,  is  Meckel's 
ganglion,  with  its  descending  palatine  branches,  etc. 

We  may  now  remove  rather  more  of  the  ramus  of  the  jaw  in 
order  to  expose  more  completely  the  internal  pterygoid  muscle. 
This  is  seen  to  arise  from  the  inner  surface  of  the  external  pterygoid 
plate,  and,  passing  downward,  backward,  and  outward,  is  attached 
to  the  inner  surface  of  the  angle  of  the  jaw.  Between  this  muscle 
and  the  inner  surface  of  the  ramus  of  the  jaw  are  the  inferior  dental 
nerve,  which  enters  the  canal  on  the  inner  surface  of  the  ramus,  and 
the  lingual,  which  is  joined  by  the  chorda  tympani.  The  internal 
lateral  ligament  of  the  jaw  may  also  be  seen  in  this  dissection. 

OPERATIONS  UPON  THE  FACE. 

Resection  of  the  Upper  Jaw. — The  chief  danger  in  this  operation 
is  from  the  entrance  of  blood  into  the  larynx.  This  may  be  avoided 
by  previously  ligating  the  external  carotid  or  by  a  preliminary 
tracheotomy  and  the  use  of  a  Trendelenburg  tampon  cannula;  or  an 
ordinary  tracheotomy  tube  may  be  used,  in  this  latter  case  packing 
the  pharynx,  through  the  mouth,  with  a  gauze  pad.  The  operation 
made  be  done  without  a  preliminary  tracheotomy  by  operating  with 
the  patient  in  the  Eose  position,  the  head  hanging  over  the  end  of 
the  table,  so  that  the  field  of  operation  is  upon  a  lower  level  than 
the  larynx.  It  is  said  that  the  dependent  position  of  the  head,  the 
Eose  position,  favors  venous  hemorrhage,  which  would  be  a  dis- 
advantage. The  operation  may  be  done  with  the  patient  in  a  half- 
sitting  position,  using  incomplete  morphin-chloroform  narcosis,  the 
patient  being  but  partly  anesthetized,  and  therefore  able  to  cough 
and  keep  the  larynx  clear  of  blood. 

The  incision  should  be  so  placed  as  to  avoid  Stenson's  duct. 

Weber's  Incision. — Eeaching  from  the  inner  angle  of  the  eye, 
the  incision  is  carried  down  alongside  of  the  nose  and  around  the 
ala  to  the  middle  line,  terminating  by  splitting  the  upper  lip.  To 
this  is  added  a  second  incision  reaching  from  the  inner  angle  of  the 
eye,  outward,  below  the  lower  margin  of  the  orbit.  This  second 
incision  should  pass  along  the  lower  edge  of  the  orbicularis  palpe- 
brarum in  order  to  avoid  cutting  into  the  substance  of  this  muscle. 
These  incisions  penetrate  to  the  bone.    Branches  of  the  facial  nerve 


OPERATIONS  UPON  THE  FACE.  71 

are  not  cut  in  making  the  incision.  The  flap  which  is  thus  marked 
out  is  reflected  outward,  and  should  be  raised  subperiosteally  if  the 
character  of  the  disease  permits.  The  infra-orbital  vessels  and  nerve 
are  cut  when  the  flap  is  separated  from  the  anterior  surface  of  the 
superior  maxilla. 


Fig.   22. — Resection  of  Upper  Jaw.     L,   Langenbeck  incision;   V,   Velpeau 
incision;  W,  Weber  incision. 


Langenbeck's  Incision. — A  flap,  its  lower  border  curved  with 
the  convexity  downward,  is  raised.  The  incision  commences  at  the 
inner  angle  of  the  eye,  and  passes  down  alongside  of  the  nose  to  a 
point  below  the  level  of  the  ala,  as  far  as  the  attachment  of  the 
upper  lip  to  the  alveolar  process  of  the  superior  maxilla;  here  it 
curves  outward,  corresponding  to  a  line  drawn  from  the  ala  of  the 


72  HEAD  AND  FACE. 

nose  to  the  lower  border  of  the  lobe  of  the  ear,  and  is  then  carried 
upward  to  a  point  over  the  prominence  of  the  cheek-bone.  This  in- 
cision does  not  divide  the  lip,  but  it  will  be  necessary  later  to  separate 
the  lip  from  its  attachment  to  the  jaw-bone.  It  divides  some  branches 
of  the  facial  nerve,  which  is  a  disadvantage.  The  front  surface  of  the 
bone  is  exposed  by  reflecting  the  flap  upward,  subperiosteal^,  if  the 
conditions  permit.  In  raising  the  flap  from  the  bone  the  infra-orbital 
vessels  and  nerve  are  divided. 

In  making  either  of  these  incisions  the  facial  artery  is  divided 
and  must  be  clamped  and  ligated. 

After  the  soft  parts  have  been  detached  from  the  bone  the  carti- 
lage of  the  nose  is  separated  from  the  nasal  notch,  and  the  soft  parts, 
corresponding  to  the  lower  margin  of  the  orbit,  raised  from  the  bone, 
and  the  tarso-orbital  fascia  cut  along  the  margin  of  the  orbit.  The 
floor  of  the  orbit  being  thus  exposed,  the  contents  of  the  orbit  are 
raised  out  of  the  way  with  a  blunt  retractor.  We  are  then  ready  to 
cut  through  the  nasal  process  of  the  superior  maxillary.  This  division 
extends  from  the  margin  of  the  nasal  notch,  across  the  nasal  process, 
as  far' as  the  lacrymai  groove  or  fossa.  It  is  necessary  to  avoid  injury 
to  the  lacrymai  sac,  the  upper  expanded  part  of  the  lacrymai  canal, 
which  is  lodged  in  the  lacrymai  depression  upon  the  lacrymai  bone. 
The  division  of  this  process  of  bone  may  be  accomplished  with  a 
chisel,  or  a  hole  may  be  made  in  the  lacrymai  bone,  which  is  very  thin, 
just  in  front  of  the  lacrymai  sac,  and  a  Gigli  saw  introduced  through 
the  orbit  and  around  the  process,  bringing  its  end  out  through  the 
nasal  notch ;  the  Gigli  saw  is  carried  around  the  bone  with  a  loop  of 
silk  in  a  curved  needle.  Probably  a  chisel  is  more  convenient  for  this 
part  of  the  operation. 

We  may  then  proceed  to  the  next  step  of  the  operation,  which 
consists  in  separating  the  jaw  from  its  attachment  to  the  malar  bone. 
This  may  be  done  with  a  chisel  or  with  a  chain  or  Gigli  saw.  The 
line  of  division  extends  through  the  maxillary  process  of  the  malar 
bone  into  the  anterior  end  of  the  spheno-maxillary  fissure.  If  this 
section  is  made  with  a  chain  or  Gigli  saw,  the  instrument  may  be 
carried  around  the  bone  with  a  loop  of  strong  silk  in  a  large,  full- 
curved  needle.  The  contents  of  the  orbit  being  well  retracted,  the 
needle  is  passed  into  the  orbit,  through  the  spheno-maxillary  fissure, 
and  then  out  through  the  zygomatic  fossa,  emerging  upon  the  face 
below  the  malar  process;  the  suture  is  then  pulled  through,  drawing 
the  saw,  which  thus  surrounds  the  malar  bone  at  its  junction  with  the 


OPERATIONS  UPON  THE  FACE. 


73 


superior  maxillary,  after  it;  the  division  may  then  be  readily  made. 
If  it  is  desired  to  take  the  malar  bone  away  in  addition  to  the  superior 
maxillary,  the  needle,  after  entering  the  spheno-maxillary  fissure,  as 
above  described,  should  be  made  to  traverse  the  temporal  fossa,  appear- 
ing above  the  upper  border  of  the  malar  bone,  so  as  to  surround  its 
frontal  process ;  after  this  process  has  been  divided  the  zygomatic  arch 


Fig.  23. —Resection  of  Upper  Jaw.  When  it  is  desired  to  leave  the  major 
part  of  the  malar  bone,  the  line  of  section  through  the  bone  should  be  as 
indicated  upon  the  right  side  of  the  skull.  If  the  malar  bone  is  to  be  re- 
moved together  with  the  superior  maxillary,  the  section  through  the  bone 
should  be  as  is  represented  upon  the  left  side  of  the  skull,  the  line  of  division 
passing  through  the  frontal  process  of  the  malar  and  the  zygoma. 


may  be  cut  through  with  the  chisel,  thus  separating  the  malar  bone 
from  its  connection  with  the  temporal  bone. 

We  are  then  ready  to  make  the  division  through  the  hard  palate ; 
this  is  best  done  as  the  last  step  of  the  operation,  after  the  other 
connections  have  been  severed,  on  account  of  the  hemorrhage  into 
the  mouth.  Before  dividing  the  hard  palate  the  muco-periosteal 
layer,  which  covers  it,  is  detached.  An  incision  is  made  in  the  muco- 
periosteal   covering  of  the  hard  plate,   commencing   anteriorly   just 


74  HEAD  AND  FACE. 

behind  the  incisor  teeth;  this  is  carried  back  along  the  side  of  the 
hard  palate,  close  to  the  alveolar  process,  as  far  as  the  attachment  of 
the  soft  palate  to  the  posterior  border  of  the  hard  palate.  With  a 
periosteum  elevator,  this  layer  is  separated  from  the  surface  of  the 
hard  palate,  as  far  as  the  middle  line ;  the  soft  palate  is  also  separated 
from  the  corresponding  half  of  the  posterior  border  of  the  hard  pal- 
ate. A  chisel  is  then  placed  in  the  middle  line  between  the  two  in- 
cisor teeth,  and  the  hard  palate  divided  down  the  middle  for  its 
whole  length.  It  is  probably  better,  in  some  cases,  to  accomplish 
this  division  with  a  saw.  For  this  purpose  we  use  a  narrow  saw, 
which  is  introduced  into  the  nasal  cavity,  after  the  first  incisor  tooth 
of  the  jaw  which  is  to  be  excised  has  been  extracted,  sawing  through 
the  floor  of  the  nasal  cavity  from  above  downward  and  from  before 
backward. 

The  jaw-bone  is  now  free  except  for  its  attachment,  behind,  to 
the  palate  bone  and  to  the  pterygoid  plate  of  the  sphenoid.  The 
floor  of  the  orbit,  which  is  very  thin,  may  be  cut  through,  just  behind 
its  anterior  margin,  with  one  or  two  strokes  of  the  chisel,  this  line 
of  section  reaching  from  the  lacrymal  fossa  across  the  floor  of  the 
orbit  into  the  spheno-maxillary  fissure.  One  should  finally  see  that 
the  soft  parts  are  separated  from  the  facial  surface  of  the  bone,  well 
beyond  the  last  molar  tooth;  this  may  be  done  with  a  few  sweeps 
of  the  knife,  cutting  close  to  the  surface  of  the  bone. 

The  body  of  the  jaw  is  seized  with  a  strong  bone  forceps, 
and,  with  a  gradually  increasing  rocking  motion,  it  is  forcibly 
wrenched  from  its  remaining  attachment.  Usually  all  of  the  palate 
bone,  except  its  orbital  process,  comes  away  with  the  superior 
maxilla  and  there  is  left  remaining  a  part  of  the  orbital  surface  of 
the  superior  maxilla  sufficient  to  support  the  contents  of  the  orbit. 
If  part  of  the  pterygoid  process  comes  away  with  the  superior  max- 
illary, the  bone  will  still  be  held  by  some  of  the  muscles  which  arise 
from  this  process, — the  internal  and  external  pterygoids, — and  it 
will  be  necessary  to  divide  these  with  a  sweep  of  the  knife  before 
the  bone  can  be  removed. 

There  is  left  a  large  bloody  space,  but,  as  a  rule,  there  is  little 
or  no  hemorrhage,  owing  to  the  tearing  of  the  blood-vessels  in 
wrenching  the  bone  free.  The  infra-orbital  vessels  and  nerve  may 
be  seen  hanging  free  in  the  wound.  The  vessels,  which  may  bleed 
freely,  should  be  seized  at  once,  clamped,  and  tied,  and  the  nerve 
cut  short.     The  other  branches  of  the  internal  maxillary  artery  also 


OPERATIONS  UPON  THE  FACE.  75 

are  exposed, — the  descending  palatine  and  spheno-palatine, — and  these 
should  also  be  clamped  and  tied. 

The  wound  may  now  be  irrigated  and  tamponed,  the  ends  of 
the  gauze  emerging  through  the  nostril.  The  incision  upon  the  face 
is  closed  with  interrupted  silk  sutures,  but,  before  doing  this,  the  edge 
of  the  muco-periosteal  flap,  which  was  raised  from  the  surface  of  the 
hard  palate,  is  stitched  with  interrupted  silk  sutures  to  the  inner  side 
of  the  cheek  along  the  line  where  this  was  separated  from  the  alveolar 
process  of  the  superior  maxilla.  The  ends  of  these  sutures  are  left 
rather  long  and  presenting  into  the  mouth,  to  facilitate  their  removal 
later. 

During  the  operation  the  back  of  the  mouth  and  the  pharynx  may 
be  kept  clear  of  blood  with  gauze  pads  on  long  holders. 

Total  Resection  of  Both  Superior  Maxillas. — This  operation  is 
analogous  to  the  preceding. 

A  curved  incision,  passing  from  the  angle  of  the  mouth  outward 
and  upward  to  the  malar  bone  on  each  side,  or  a  double  Weber  in- 
cision, may  be  used. 

The  nasal  septum,  vomer,  is  divided  with  bone  scissors,  and  the 
soft  parts  as  a  whole,  including  the  nose,  are  detached  and  reflected 
upward,  or  if  a  double  Weber  incision  is  used  the  lateral  flaps  are 
separated  from  the  bone  and  reflected  outward. 

The  attachments  of  the  superior  maxillas  are  then  divided  as  in 
the  preceding  operation,  except  that  it  will  not  be  necessary  to  split 
or  cut  through  the  hard  palate,  as  this  is  taken  away  entirely.  If 
possible,  the  muco-periosteal  covering  of  the  hard  palate  should  be 
stripped  off  and  preserved;  this  is  done  by  separating  it,  with  an 
elevator,  through  a  curved  incision  which  penetrates  through  this 
layer  down  to  the  bone  and  which  is  placed  just  inside  the  line  of 
the  teeth.  The  soft  palate,  at  its  attachment  to  the  posterior  border 
of  the  hard  palate,  is  also  completely  separated.  Finally,  with  lion- 
jaw  forceps,  the  bone  is  forcibly  wrenched  free  as  in  the  preceding 
operation. 

The  soft  parts  are  brought  together  with  silk  sutures,  first  uniting 
the  edge  of  the  muco-periosteal  flap,  which  was  raised  from  the  hard 
palate,  to  the  inner  side  of  the  cheeks,  corresponding  to  the  line 
where  they  were  separated  from  the  alveolar  process. 

To  Drain  the  Antrum  of  Highmore.  Through  the  Tooth 
Socket. — Empyema  is  frequently  associated  with  carious  teeth. 
These  or  their  remaining  roots  ma}r  be  extracted  and  an  opening 


76  HEAD  AND  FACE. 

made  into  the  antrum  by  gouging  out  the  alveolar  cavity,  which  is 
often  found  to  be  carious.  This  may  be  done,  as  a  rule,  with  a  sharp 
spoon  or  with  a  narrow  chisel.  The  chisel  should  be  directed  upward 
toward  a  point  corresponding  to  the  middle  of  the  lower  margin 
of  the  orbit.  Such  an  opening,  if  made  sufficiently  large,  provides 
satisfactory  drainage  from  the  antrum.  A  strip  of  gauze  may  be 
introduced  to  drain  the  cavity  and  to  prevent  the  entrance  of  par- 
ticles of  food.  The  opening  should  be  made  through  the  alveolus 
of  the  first  molar  tooth. 

Theotjgh  the  Anterior  Wall. — Drainage  may  be  established 
by  making  an  opening  through  the  front  wall  of  the  antrum.  The 
upper  lip  is  everted  and  the  mucous  membrane  cut  and  the  soft  parts 
separated  from  the  front  surface  of  the  bone  with  the  periosteum 
elevator.  The  front  wall  of  the  antrum  is  perforated  through  the 
canine  fossa  just  above  and  to  the  outer  side  of  the  canine  tooth. 
The  socket  of  this  tooth  is  marked  by  a  prominent  ridge. 

After  the  periosteum  has  been  stripped  off  the  bone  a  good- 
sized  opening  is  made  into  the  antrum  with  the  chisel  or  with  a 
strong,  sharp-pointed  perforator  or  with  a  drill.  The  instrument 
should  be  directed  upward  and  somewhat  backward  toward  the  floor 
of  the  orbit,  but  care  should  be  taken  to  avoid  entering  the  antrum 
abruptly  with  such  force  as  to  endanger  the  floor  of  the  orbit.  A 
drainage  tube  may  be  introduced  and  left  in  place  for  several  days 
until  the  drainage  opening  is  well  established.  It  is  advisable  to 
use  a  tube  with  a  bulbed  end  to  prevent  its  slipping  out. 

This  operation  may  well  be  combined  with  drainage  through  the 
tooth  socket  as  described  above.  Both  operations  may  be  done  with 
the  patient  in  the  Eose  position  or  with  partial  morphin-chloroform 
anaesthesia. 

Through  the  Lateral  Wall  of  the  Nose. — Mikulicz  advises 
making  an  opening  in  the  lateral  wall  of  the  nose  just  below  the 
middle  of  the  inferior  turbinated.  This  may  be  done  with  a  sharp- 
pointed  perforator  somewhat  bent  upon  itself  near  the  end.  The 
bone  is  thin,  and  the  operation  is  readily  done  except  when  the  nasal 
cavity  is  narrow  or  the  inferior  turbinated  much  hypertrophied. 

Resection  of  Half  of  the  Lower  Jaw. — The  incision  commences 
at  the  middle  of  the  chin  and  follows  along  the  lower  border  of  the 
body  of  the  jaw  as  far  as  the  angle,  whence  it  is  continued  upward 
along  the  posterior  border  of  the  ramus  as  high  as  the  lower  border 
of  the  lobe  of  the  ear  (one  may  cut  to  this  point  without  danger  of 


OPERATIONS  UPON  THE  FACE.  77 

injuring  the  facial  nerve;  see  Fig.  81).  This  incision  for  its  whole 
extent  should  reach  to  the  bone.  There  may  he  added  in  front  a 
vertical  incision,  splitting  the  lower  lip  through  the  middle  line,  but 
this  is  usually  unnecessary.  The  facial  vessels  are  severed  in  making 
the  incision  along  the  lower  border  of  the  body  of  the  jaw-bone,  and 
these  must  be  clamped  and  tied. 

If  the  glands,  etc.,  in  the  submaxillary  region  are  diseased,  in- 
stead of  the  above-described  incision  one  may  be  made  which  com- 
mences anteriorly,  in  the  middle  line,  at  the  lower  border  of  the 
jaw,  from  which  point  it  passes  backward  and  somewhat  downward 
across  the  submaxillary  triangle,  deviating  from  the  lower  border 
of  the  jaw  as  it  passes  backward,  as  far  as  the  anterior  border  of  the 
sterno-mastoid  muscle,  whence  it  is  turned  upward  toward  the  apex 
of  the  mastoid  process.  This  incision  passes  through  the  integu- 
ment and  the  platysma.  The  flap  which  is  thus  outlined  is  turned 
up  over  the  side  of  the  face,  and  we  are  then  enabled,  as  a  prelimi- 
nary step,  to  clear  out  the  submaxillary  triangle,  and  before  doing 
this  we  can,  if  desired,  easily  expose  and  ligate  the  external  carotid 
artery.  Some  surgeons  precede  the  operation  with  a  preliminary 
tracheotomy,  introducing  a  tampon  cannula;  or  an  ordinary  tube 
may  be  introduced  and  the  pharynx  tamponed  through  the  mouth. 
These  measures  eliminate  the  danger  of  blood  being  inspired  into 
the  trachea. 

After  having  cleaned  out  the  submaxillary  triangle,  if  this  has 
been  necessary,  the  soft  parts  are  separated  from  the  external  sur- 
face of  the  body  and  ramus  of  the  jaw,  back  as  far  as  the  angle, 
working  close  to  the  surface  of  the  bone;  the  attachment  of  the 
masseter  is  thus  separated  from  the  ramus.  The  separation  of  the 
masseter  and,  in  fact,  the  soft  parts  from  the  body  of  the  bone  as 
well,  may  be  accomplished  with  a  periosteum  elevator,  occasionally 
snipping  with  the  knife.  It  is  desirable,  if  the  nature  of  the  con- 
dition present  permits,  to  make  this  separation  subperiosteally.  In 
the  mass  of  soft  parts  which  is  raised  from  the  outer  surface  of  the 
ramus  of  the  jaw  are  included,  besides  the  masseter  muscle,  the 
parotid  gland  and  Stenson's  duct,  the  facial  nerve,  and  the  temporal 
artery.  None  of  these  structures  are  injured  if  the  operator  works 
close  to  the  surface  of  the  bone.  Finally,  with  a  clean  cut,  the  cav- 
ity of  the  mouth  is  entered,  incising  the  mucous  membrane  close  to 
the  anterior  border  of  the  ramus  and  along  the  dental  margin  of  the 
body  of  the  jaw  as  far  as  the  middle  line ;  in  this  way  the  outer  sur- 


78  HEAD  AND  FACE. 

face  of  the  lower  jaw,  including  the  teeth,  is  laid  bare.  Anteriorly, 
where  the  bod}'  of  the  jaw  is  to  be  divided,  a  tooth  is  extracted  and 
the  floor  of  the  mouth,  close  to  the  bone,  incised,  so  that  the  chain 
or  Gigli  saw  may  be  carried  around  the  bone.  This  is  done  with  a 
loop  of  strong  silk  in  a  large  curved  needle.  This  division  may  also 
be  accomplished  with  a  metacarpal  saw.  The  section  through  the 
body  of  the  jaw  in  front,  should,  if  possible,  be  made  a  little  external 
to  the  middle  line,  toward  the  side  of  the  disease,  in  order  to  avoid 
separating  the  genio-hyoid  and  genio-hyoglossus  muscles  from  their 
attachment  to  the  tubercles  on  the  inner  aspect  of  the  symphysis 
mentis.  If  these  muscles  are  separated  from  their  attachment  to  the 
jaw  there  is  a  great  tendency,  both  during  and  after  the  operation, 
for  the  tongue  to  drop  back  into  the  pharynx,  closing  down  the  epi- 
glottis and  thus  greatly  interfere  with  the  patient's  breathing. 

After  the  bone  has  been  divided  anteriorly  its  free  end  is  seized 
with  a  bone  forceps  and  drawn  outward,  thus  putting  the  structures 
attached  to  its  inner  surface  (floor  of  the  mouth)  on  the  stretch,  and 
they  are  then  divided  close  to  the  dental  margin  (teeth)  with  a 
scalpel.  If  the  condition  of  the  periosteum  permits,  these  parts  may 
be  separated  from  the  inner  surface  of  the  jaw  subperiosteal^  with 
an  elevator.  The  body  of  the  bone,  still  firmly  grasped  with  the  bone 
forceps  and  being  now  freely  movable,  is  dragged  forcibly  downward 
and  out  of  the  wound  so  that  the  operator  can  reach  the  coracoid 
process  to  which  the  tendon  of  the  temporal  muscle  is  attached;  this 
is  separated  with  a  knife,  cutting  close  to  the  bone  and  avoiding  the 
internal  maxillary  artery,  and  the  bone  is  then  still  further  luxated. 
Behind,  attached  to  the  inner  surface  of  the  ramus  of  the  jaw,  at  the 
angle,  is  the  internal  pterygoid  muscle;  this  is  also  cut  away  close 
to  the  surface  of  the  bone. 

The  inferior  dental  vessels  and  nerve  enter  the  jaw-bone 
through  the  inferior  dental  canal  on  the  inner  surface  of  the  ramus; 
these  structures  may  be  cut  or  torn,  but  before  being  cut  they  should 
be  grasped  with  an  artery  forceps ;  later  the  vessels  are  tied  and  the 
forceps  removed,  liberating  the  nerve.  If  the  inferior  dental  should 
bleed  in  the  sawn  surface  of  the  remaining  half  of  the  bone  this  may 
be  stopped  by  plugging  the  orifice  of  the  canal  with  a  strand  of  cat- 
gut. 

The  flap  of  soft  parts  is  drawn  forcibly  upward,  and  the  bone, 
still  held  with  the  bone  forceps,  dragged  downward;  so  that  the 
outer  wall  of  the  capsule  of  the  temporo-maxillary  joint  may   be 


OPERATIONS  UPON  THE  FACE.  79 

reached  with  the  point  of  a  sharp  knife  and  incised;  the  tendon  of 
the  external  pterygoid,  which  is  attached  to  the  front  of  the  neck 
of  the  condyle,  is  likewise  divided.  In  cutting  these  structures  the 
knife  is  kept  applied  close  to  the  surface  of  the  bone  in  order  to 
avoid  the  internal  maxillary  and  the  temporal  arteries.  The  bone 
may  now  be  readily  twisted  out  of  its  socket. 

If  it  should  be  necessary  to  separate  the  muscles  of  the  tongue 
from  their  attachment  to  the  symphysis  of  the  jaw,  a  thick  silk 
suture  should  be  previously  passed  through  its  tip,  to  be  used  as 
a  tractor  to  prevent  its  being  drawn  backward  into  the  pharynx  and 
closing  the  larynx  and  interfering  with  respiration.  It  is  probably 
advisable  to  introduce  such  a  suture  in  all  cases. 

The  cut  edge  of  the  mucous  membrane  which  was  separated 
from  the  inner  aspect  of  the  jaw-bone  is  now  accurately  sutured  to 
the  corresponding  edge  of  the  mucous  membrane  which  was  separated 
from  the  outer  aspect,  except  for  a  short  space  behind,  through  which 
the  cavity  of  the  mouth  is  drained;  these  sutures  should  be  of  silk, 
knotted  on  the  inside  of  the  mouth,  and  the  ends  left  sufficiently 
Jong  to  allow  of  their  ready  removal  later. 

The  edges  of  the  skin  are  approximated  with  interrupted  sutures 
except  at  the  posterior  part  where  the  drain  emerges. 

For  the  purpose  of  facilitating  drainage,  the  wound  is  loosely 
packed  with  iodoform  gauze,  reaching  into  the  cavity  of  the  mouth. 
This  may  be  removed  after  a  few  days,  when  a  sinus  is  established 
through  which  all  secretions  from  the  mouth  may  find  exit. 

Kesection  of  Half  of  the  Eody  of  the  Lower  Jaw.  —  A  strong, 
thick  suture  is  passed  through  the  tongue  for  use  as  a  tractor,  if 
this  becomes  necessary.  An  incision  is  made  along  the  lower  bor- 
der of  the  body  of  the  jaw  from  the  middle  line  in  front  to  the 
junction  of  the  body  and  ramus  just  beyond  the  last  molar,  behind; 
this  incision  penetrates  to  the  bone.'  In  many  cases  the  facial  artery, 
where  it  curves  over  the  lower  border  of  the  body  of  the  jaw,  just 
in  front  of  the  masseter,  is  divided;  but  frequently  this  may  be 
avoided.  If  the  vessel  is  cut  it  must  be  clamped  and  ligated.  There 
may  be  added  anteriorly  a  vertical  incision  which  splits  the  lower 
lip  in  the  middle  line ;  but,  as  a  rule,  this  is  unnecessary,  and  should 
be  avoided. 

With  the  elevator  or  knife,  working  close  to  the  surface  of  the 
bone,  the  soft  parts  are  separated  from  the  outer  surface  of  the  body 
of  the  jaw,  finally  cutting  through  the  mucous  membrane  close  to 


80  HEAD  AND  FACE. 

the  teeth  and  thus  entering  the  mouth  and  exposing  the  outer  sur- 
face of  the  body  of  the  bone  and  the  teeth. 

The  floor  of  the  mouth  is  now  perforated,  anteriorly,  near  the 
middle  line,  close  to  the  inner  surface  of  the  bone,  and,  after  ex- 
tracting a  tooth,  the  Gigli  or  chain  saw  is  introduced,  being  carried 
around  the  jaw  with  a  loop  of  silk  in  a  large  curved  needle,  and  the 
bone  is  then  sawn  through;  this  section  should  be  made  to  the  side 
of  the  middle  line  in  order  not  to  disturb  the  attachment  of  the 
muscles  of  the  tongue  to  the  symphysis.  If  the  end  of  the  divided 
bone  bleeds,  this  may  be  controlled  by  plugging  the  orifice  of  the 
canal  which  contains  the  nutrient  artery.  The  end  of  that  half  of 
the  bone  which  is  to  be  excised  is  seized  with  the  bone  forceps  and 
drawn  strongly  outward,  thus  putting  the  soft  parts  attached  to  its 
inner  surface  (floor  of  the  mouth)  upon  the  stretch.  These  parts 
are  separated  from  the  inner  surface  of  the  bone  as  far  back  as  the 
junction  of  the  body  with  the  ramus — beyond  the  last  molar  tooth. 
This  may  be  done  bluntly  with  an  elevator,  separating  subperios- 
teally,  or,  if  this  is  contra-indicated  on  account  of  the  character  of 
the  disease,  the  soft  parts,  including  the  mucous  membrane,  may  be 
simply  cut  away  from  the  bone  with  the  knife.  After  having  thus 
stripped  the  body  of  the  bone  of  its  soft  parts,  both  upon  its  outer 
and  its  inner  or  buccal  surface,  the  saw  is  applied  just  behind  the 
last  molar  tooth  and  the  bone  cut  through.  This  may  be  done  Avith 
the  chain  or  Gigli  saw  or  with  a  narrow  metacarpal  saw.  While  the 
bone  is  being  divided  it  should  be  drawn  well  downward  with  the 
bone  forceps. 

Hemorrhage  from  the  cut  surface  of  the  bone  is  controlled  with 
a  plug  of  catgut,  which  is  packed  into  the  orifice  of  the  dental  canal. 

The  mucous  membrane,  which  was  separated  from  the  outer 
surface  of  the  segment  of  bone  which  has  been  resected,  is  sutured 
to  the  cut  edge  of  the  parts  which  were  separated  from  the  inner 
surface  of  the  bone.  This  closes  in  the  cavity  of  the  mouth,  and 
may  be  done  with  interrupted  silk  sutures  tied  within  the  mouth, 
the  ends  being  left  long  so  that  they  may  be  readily  removed. 

The  incision  in  the  skin  is  closed  in  part,  leaving  the  posterior 
end  open  for  drainage.  It  is  probably  wise,  in  most  cases,  to  leave  ' 
a  small  opening  through  the  mucous  membrane  also,  so  that  the 
cavity  of  the  mouth  may  be  drained;  in  this  case  the  gauze,  which 
is  introduced  into  the  posterior  portion  of  the  skin  incision,  is  packed 
into  the  mouth. 


OPERATIONS  UPON  THE  FACE.  81 

Resection  of  the  Entire  Body  of  the  Lower  Jaw. — This  is  anal- 
ogous to  the  preceding  operation,  but  special  care  must  be  exercised 
to  guard  against  the  tongue  dropping  back  into  the  pharynx  after 
the  attachment  of  the  muscles,  which  pull  it  forward,  have  been 
separated  from  the  inner  surface  of  the  symphysis.  This  accident 
may  be  prevented  by  passing  a  ligature  through  the  tip  of  the  tongue 
by  which  traction  may  be  made.  There  is  also  considerable  danger 
of  the  tongue  dropping  back  and  obstructing  the  breathing  after  the 
operation,  and  this  accident  might  easily  cause  the  death  of  the 
patient;  so  that  the  tractor  should  be  allowed  to  remain  in  the 
tongue  and  fixed  outside. 

The  jaw-bone  is  divided  in  the  middle  line,  and  then  each  half 
is  resected  separately  as  described  in  the  preceding  operation. 

Resection  of  Part  of  the  Body  of  the  Lower  Jaw  in  Continuity. 
Feom  Within  the  Mouth. — Precautions  must  be  taken  to  prevent 
blood  entering  the  larynx  during  the  operation  (see  "Eesection  of  the 
Upper  Jaw,"  etc.).  A  mouth-gag  is  introduced  and  an  incision  is 
made  through  the  mucous  membrane  on  either  side  of  the  teeth,  and 
the  soft  parts  separated  from  the  inner  and  outer  surfaces  and  from 
the  lower  border  of  the  segment  of  the  jaw-bone  that  is  to  be  excised, 
with  an  elevator.  A  tooth  is  then  extracted  and  the  Gigli  saw  passed 
around  the  bone  with  a  loop  of  silk  in  a  large  curved  needle  and  the 
bone  divided;  this  procedure  is  repeated  at  the  other  end  of  the 
segment  of  bone  which  is  to  be  excised.  The  hemorrhage  from  the 
cut  ends  of  the  bone  is  controlled  by  a  plug  of  catgut  packed  into 
the  dental  canal.  The  soft  parts  may  be  separated  from  the  surface 
of  the  bone  subperiosteal^,  as  above  described,  but  in  most  cases  this 
is  not  permissible  on  account  of  the  character  of  the  disease.  After 
removal  of  the  segment  of  bone  the  edges  of  the  mucous  membrane 
may  be  brought  together,  at  least  in  part,  by  interrupted  silk  sutures. 
A  small  opening  may  be  made  externally  through  the  skin  for 
drainage. 

If  the  anterior  portion  of  the  body  is  resected,  necessitating  the 
separation  of  the  tongue  muscles  from  the  symphysis,  proper  meas- 
ures must  be  taken  to  guard  against  the  tongue  dropping  back  upon 
the  epiglottis  and  larynx.  The  operation  done  from  within  the 
mouth  is  ordinarily  rather  disadvantageous,  as  it  is  rather  difficult 
to  properly  drain  the  wound  afterward. 

Feom  Without. — An  incision  is  made  along  the  lower  border 
of  the  body  of  the  bone  corresponding  to  that  part  of  the  bone 


82  HEAD  AND  FACE. 

which  is  to  be  resected  and  reaching  down  to  the  surface  of  the  bone. 
Usually  it  is  not  necessary  to  split  the  lower  lip.  The  soft  parts  are 
separated  from  the  outer  surface  of  the  body  of  the  bone  with  the 
elevator,  if  permissible  subperiosteally,  and  the  mucous  membrane 
then  incised  close  to  the  teeth,  thus  opening  into  the  mouth.  Corre- 
sponding to  the  points  at  which  the  bone  is  to  be  divided  the  teeth 
are  extracted  and  incisions  made  in  the  floor  of  the  mouth  close  to 
the  bone  to  allow  the  passage  of  the  Gigli  saw;  this  is  carried  around 
the  bone  with  a  loop  of  silk  in  a  full  curved  needle  and  the  bone 
then  divided.  The  segment  of  bone,  which  has  been  thus  loosened 
and  to  the  inner  aspect  of  which  the  soft  parts  of  the  floor  of  the 
mouth  are  still  attached,  is  seized  with  the  bone  forceps,  and  the 
soft  parts  (mucous  membrane  and  muscles  of  the  floor  of  the  mouth) 
are  then  separated  with  the  elevator  or  cut  with  the  knife  close  to 
the  surface  of  the  bone  and  near  its  alveolar  margin. 

Hemorrhage  from  the  bone  may  be  controlled  by  plugging  its 
nutrient  canal  with  a  piece  of  catgut. 

The  mucous  membrane,  which  was  separated  from  the  outer 
surface  of  the  resected  segment,  is  united  to  that  which  was  sepa- 
rated from  the  inner  surface  with  several  interrupted  silk  sutures, 
tied  within  the  mouth,  in  this  way  closing  in  the  cavity  of  the 
mouth.     The  external  wound  is  partly  closed  and  drained. 

If  the  part  resected  corresponds  to  the  anterior  portion  of  the 
body  of  the  jaw-bone,  it  is  desirable  to  secure  the  tongue  by  passing 
a  silk  suture  through  its  tip. 

Resection  of  Part  of  the  Body  of  the  Lower  Jaw  (Not  Through 
Entire  Thickness,  Not  in  Continuity). — Practically  as  described  in 
the  preceding  operation,  working  either  from  within  the  mouth  or 
without.  The  operation  consists  in  resecting  the  diseased  part  of 
the  bone  and  leaving  a  portion  of  the  body,  of  greater  or  less  thick- 
ness, as  a  bridge  to  preserve  the  continuity  of  the  bone  and  prevent 
deformity,  and  to  facilitate  the  application  of  an  apparatus.  The 
removal  of  the  bone  may  be  effected  with  a  chisel  or  with  the  cutting 
bone  forceps.     This  operation  is  but  seldom  practiced. 

Resection  of  Temporo-maxillary  Articulation. — This  operation 
consists,  as  a  rule,  in  the  extirpation  of  the  condyle  of  the  lower  jaw. 
The  interarticular  cartilage  and  the  glenoid  cavity  are  not  interfered 
with  in  most  cases.  The  operation  is  performed  for  ankylosis  and 
disease  of  the  joint.  It  may  be  found  necessary  to  resect  the  joint  on 
both  sides. 


OPERATIONS  UPON  THE  FACE.  83 

An  angular  incision  is  employed.  The  descending  arm  com- 
mences at  the  lower  border  of  the  zygoma  about  three-quarter  inch 
anterior  to  the  tragus  and  passes  downward  for  a  distance  of  about 
one  inch.  This  incision  lies  in  front  of  the  temporal  artery  and 
should  not  reach  low  enough  to  injure  Stenson's  duct  or  the  facial 
nerve.  These  latter  structures  rest  upon  the  masseter  muscle  and 
pass  from  behind  forward  below  and  parallel  with  the  zygoma.  From 
the  upper  end  of  the  vertical  incision  another  is  carried  forward 
along  the  lower  border  of  the  zygomatic  arch  for  a  distance  of  from 
one  and  one-half  to  two  inches.  The  flap,  consisting  of  skin  and 
fat,  is  reflected  downward  and  strongly  retracted,  exposing  the  upper 
part  of  the  masseter  muscle.  With  a  blunt  hook  the  posterior  edge 
of  the  wound,  including  the  anterior  margin  of  the  parotid  gland 
and  temporal  artery,  etc.,  is  retracted  backward. 

The  joint  is  exposed  by  detaching  the  masseter  muscle  from 
the  lower  border  of  the  zygoma  to  a  sufficient  extent  with  the  peri- 
osteum elevator.  The  capsule  is  incised  in  a  vertical  direction  and 
also  detached  with  the  elevator.  The  condyle  is  thus  exposed  and 
may  be  removed  by  dividing  the  neck  close  to  the  articular  surface 
with  the  chisel  or  Gigli  saw.  The  condyle  is  seized  with  small  bone- 
forceps  and  any  remaining  soft  parts  cut  close  to  the  bone  and  the 
condyle  thus  removed.  It  is  desirable  to  leave  as  much  of  the  tendon 
of  the  external  pterygoid  attached  to  the  neck  of  the  bone  as  pos- 
sible. It  is  advisable  in  most  cases,  especially  of  disease,  to  estab- 
lish temporary  drainage  by  leaving  a  thin  strip  of  gauze  in  the 
wound.    The  incision  is  closed  except  where  the  drain  emerges. 

Division  of  the  Second  and  Third  Branches  of  the  Trifacial 
Nerve  at  the  Base  of  the  Skull  (Kronlein's  Modification  of  Liicke's 
Operation). — This  operation  consists  in  exposing  the  second  and 
third  divisions  of  the  fifth  nerve  as  they  emerge  from  the  skull  and 
dividing  them  or  twisting  them  free  from  their  origin. 

An  incision  marking  out  a  rounded  skin-flap,  with  its  convexity 
downward  and  its  base  corresponding  to  the  upper  border  of  the 
zygomatic  arch,  is  made.  It  commences  anteriorly,  one  finger's 
breadth  behind  the  external  angular  process,  and  terminates  behind, 
just  in  front  of  the  tragus  (see  Fig.  18).  This  flap,  which  consists  of 
the  skin  and  subcutaneous  fascia,  is  raised  from  the  deep  fascia 
covering  the  parotid  gland  and  masseter  muscle,  and  is  reflected 
upward,  thus  exposing  the  arch  of  the  zygoma  and  the  lower  portion 
of  the  temporal  fascia,  which  is  attached  to  the  upper  border  of  the 


84  HEAD  AND  FACE. 

arch.  The  incision  does  not  reach  low  enough  to  injure  the  facial 
nerve  or  Stenson's  duct.  Bleeding  points  are  clamped  and  ligated 
as  the  operation  progresses. 

The  temporal  fascia  attached  to  the  upper  border  of  the 
zygomatic  arch  is  incised  along  this  border  of  the  arch,  and  the  arch 
sawn  through:  first,  posteriorly  and  then  anteriorly.  Before  mak- 
ing this  division  of  the  arch  holes  should  be  drilled  for  the  purpose 
of  wiring  the  detached  segment  in  position  later.  In  dividing  the 
arch  anteriorly  it  is  necessary  to  get  well  forward  so  as  to  include 
as  much  of  the  length  of  the  arch  as  possible;  the  line  of  division 
should  not  be  from  above  directly  downward,  but  from  above 
obliquely  downward  and  forward.  This  segment  of  the  arch,  carry- 
ing the  attached  masseter  muscle  with  it,  is  reflected  downward, 
exposing  the  coracoid  process  of  the  ramus  of  the  lower  jaw  and 
the  attached  temporal  tendon.  This  process,  after  making  drill  holes 
for  subsequent  wiring,  is  cut  away,  the  line  of  section  extending 
from  the  deepest  part  of  the  sigmoid  notch  obliquely  downward  and 
forward  so  as  to  include  practically  all  that  part  of  the  ramus  which 
corresponds  to  the  attachment  of  the  temporal  tendon.  This  seg- 
ment of  bone,  carrying  the  temporal  tendon,  is  reflected  upward, 
and  held  thus  with  a  retractor.  The  external  pterygoid  muscle,  and 
the  internal  maxillary  artery  which  passes  obliquely  across  its  outer 
surface,  may  now  be  recognized.  It  is  well  to  tie  the  vessel  double 
and  cut  it.  With  the  elevator  the  attachment  of  the  external  ptery- 
goid is  separated  from  the  under  surface  of  the  great  wing  of 
the  sphenoid  and  drawn  downward.  The  finger  is  introduced 
into  the  space  above  the  upper  border  of  the  muscle  and  is  passed 
inward  close  to  the  under  surface  of  the  bone  (base  of  the  skull), 
feeling  for  the  posterior  sharp  edge  of  the  external  pterygoid  plate 
and  searching  for  the  foramen  ovale,  which  is  directly  behind  and 
a  little  external  to  the  root  or  base  of  the  pterygoid  process,  external 
pterygoid  plate.  We  should  recognize  the  thick  trunk  of  the  in- 
ferior maxillary,  or  third,  division  of  the  fifth  nerve  as  it  emerges 
from  the  foramen  ovale;  directly  behind  this,  the  middle  menin- 
geal artery,  surrounded  by  the  two  roots  of  the  auriculotemporal 
nerve,  is  seen  passing  upward  to  enter  the  skull  through  the  foramen 
spinosum  (see  Fig.  21).  The  inferior  maxillary  division  is  seized  with 
a  hook  and  drawn  forward  and  cut,  and  then  the  stump,  grasped  with 
a  forceps,  is  twisted  free  from  its  origin  at  the  Gasscrian  ganglion. 
Usually  the  motor  root  is  grasped  at  the  same  time  and  included 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  85 

with  it.  We  then  penetrate  into  the  spheno-maxillary  fossa,  and 
in  the  upper  part  of  this  cavity,  the  superior  maxillary,  or  second, 
division  of  the  fifth  nerve,  just  before  it  enters  the  infra-orbital 
canal,  is  seized  with  the  hook  and  drawn  out  and  cut,  and  then  like- 
wise twisted  away  from  the  G-asserian  ganglion.  The  Eustachian 
tube  is  located  close  to  the  inner  side  of  the  inferior  maxillary  nerve, 
and,  therefore,  as  soon  as  this  trunk  of  the  nerve  is  accessible,  one 
should  not  penetrate  deeper  into  the  wound  for  fear  of  injuring  the 
Eustachian  tube  and  causing  infection  of  the  wound. 

The  coracoid  process  is  reunited  to  the  ramus  of  the  jaw  with 
a  wire  suture  and  the  segment  of  the  zygomatic  arch  is  likewise 
replaced  and  wired.     The  skin  incision  is  then  closed. 

Operations  upon  the  Peripheral  Branches  of  the  Trifacial  "Nerve. 
—  The  supra-orbital,  infra-orbital,  inferior  dental  and  lingual 
branches  are  sometimes  attacked  for  the  relief  of  pain. 

The  supra-orbital  and  infra-orbital  branches  may  be  exposed 
through  an  incision  above  or  below  the  orbit. 

The  inferior  dental  may  be  reached  through  an  incision  in  the 
side  of  the  mouth,  reaching  from  behind  the  upper  to  behind  the  lower 
last  molar  tooth.  The  finger  is  inserted,  through  the  incision,  between 
the  internal  pterygoid  muscle  and  ramus  of  the  jaw  and  the  spine  that 
marks  the  orifice  of  the  inferior  dental  canal  is  recognized.  The  nerve 
is  secured  with  a  blunt  hook  just  before  it  enters  the  canal,  and  is 
drawn  out  of  the  wound  and  may  then  be  stretched,  divided,  etc. 

The  lingual  nerve  may  be  divided  for  relief  of  pain  in  inoperable 
cancer  of  the  tongue.  The  nerve  is  exposed  through  an  incision  in  the 
floor  of  mouth  close  to  the  side  of  the  tongue  and  opposite  the  last 
molar  tooth.  The  nerve  is  hooked  out  of  the  incision  and  a  portion  of 
its  length  resected. 

CONGENITAL   DEFORMITIES  OF  THE  FACE. 

The  Development  of  the  Face.  —  About  the  twelfth  day  the 
arrangement  of  the  head  end  of  the  embryo  is  quite  simple.  A 
cross  section  shows  it  to  consist  of  two  tubes,  one  being  situated 
in  front  of  the  other.  The  anterior  is  the  blind,  head  end  of  the 
alimentary  tube:  the  future  pharynx.  The  posterior  is  the  enlarged 
neural  tube  which  is  later  developed  into  the  brain.  The  anterior 
wall  of  this  upper,  head  end  of  the  alimentary  tube  is  called  the 
"oral  plate,"  and  marks  the  location  of  the  future  mouth  and  face. 


86 


HEAD  AND  FACE. 


A  sagittal  section  will  also  show  this  relationship,  and  further  that 
the  neural  tube  not  only  lies  behind  the  alimentary  tube,  but  also 


Fig.  24—  Transverse  Section  of  the  Head  End  of  an  Embryo  Twelve  Days 
Old.    A,  alimentary  tube  ;  N,  neural  tube  ;  NC,  notochord  ;  OP,  oral  plate. 

arches  forward  above  the  upper  end  of  the  latter  like  a  hood,  over- 
riding it  anteriorly.     This  upper  part  of  the  neural  tube,  which 


£_NC 


Fig.  25.— Sagittal  Section  of  the  Head  End  of  an  Embryo  Twelve  Days 
Old.  A,  alimentary  tube  ;  FB,  vesicle  of  the  forebrain  overriding  the  end  of 
the  alimentary  tube  ;  N,  neural  tube  ;  NC,  notochord ;  OP,  oral  plate  (site  of 
future  mouth),  which  ruptures  during  the  fourth  week. 

projects  forward  over  the  end  of  the  alimentary  tube,  is  called  the 
vesicle  of  the  forebrain. 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  87 

In  the  third  week  there  may  be  seen,  upon  either  side  of  the 
head  end  of  the  embryo,  four  transverse  plates  or  ribs  of  tissue 
which  are  separated  from  one  another  by  deep  fissures,  or  clefts. 
The  thickened  plates  are  called  visceral  arches,  and  the  intervening 
spaces,  or  fissures,  visceral  clefts.  Within  the  alimentary  tube,  upon 
its  inner  aspect,  there  may  be  seen  corresponding  arches  and  clefts. 
These  arches  are  simply  thickenings  or  ribs  in  the  lateral  walls  of 
the  head  end  ("schlund,"  pharynx)  of  the  alimentary  tube.  Each 
mass  consists  of  mesoblast,  covered  upon  its  outer  surface  by  the 
epidermic  layer,  which  covers  the  whole  exterior  of  the  body,  and 
upon  its  inner  surface  by  the  endodermic  layer,  which  lines  the 
whole  inner  surface  of  the  alimentary  tube.  Between  the  arches, 
at  the  bottom  of  any  two  opposed  clefts,  the  wall  of  tissue  is  ex- 
tremely thin;  consists  practically  of  the  outer  (epidermic)  and  the 
inner  (endodermic)  layers.  The  uppermost  of  these  visceral  arches, 
that  concerned  in  the  formation  of  the  face,  is  the  thickest.  It 
extends  forward,  and  in  front,  where  it  is  narrower,  unites  in  the 
middle  line,  with  its  fellow  of  the  opposite  side  to  form  the  mandib- 
ular arch,  which  represents  the  future  lower  jaw.  The  second  arch 
is  less  prominent  than  the  first,  and  as  it  passes  forward  is  directed 
somewhat  upward.  This  second  arch  does  not  reach  as  far  as  the 
middle  line.  The  third  and  fourth  arches  are  still  less  prominent 
and  still  shorter.  These  lower  three  arches  do  not  join  with  their 
fellows  across  the  middle  line  in  front,  but  are  continued  into  the 
plate  of  tissue  which  forms  the  front  wall  of  the  (schlund)  pharynx. 
From  above  downward  these  arches  overlap  and  partially  conceal 
each  other;  so  that  the  third  and  fourth,  especially  the  fourth,  are 
almost  entirely  concealed  by  the  first  and  second.  The  uppermost 
arch  appears  earliest.  The  appearance  of  these  arches  is  the  first 
indication  that  marks  the  commencement  of  the  formation  of  the 
face. 

Owing  to  the  progressive  growth  of  the  visceral  arches,  which 
causes  a  thickening  of  the  parts  that  immediately  adjoin  the  area 
already  mentioned  as  the  oral  plate,  and  on  account  of  the  presence 
of  the  prominent  overhanging  forebrain  vesicle  (neural  tube)  above, 
the  oral  plate  becomes  relatively  depressed,  and  we  have  thus,  in 
its  stead,  a  distinct  fossa,  which  is  called  the  oral  pit.  The  oral  pit 
is  bounded  above  by  the  overhanging  forebrain  vesicle  and  below 
and  upon  the  sides  by  the  first  visceral  arches.  These  are  the  parts 
which  immediately  surround  the  oral  pit  and  which  are  finally  de- 


88  HEAD  AND  FACE. 

veloped  into  the  face;  the  oral  pit  represents  the  future  oral  and 
nasal  cavities. 

The  second,  third,  and  fourth  visceral  arches  are  not  concerned 
in  the  formation  of  the  face. 

The  next  change  noticed  in  the  parts  about  the  oral  pit  is  the 
appearance  of  a  thick,  rounded  mass  or  process  upon  the  upper  back 
part  of  the  first  visceral  arch  of  either  side;  this  is  called  the  supe- 
rior maxillary  process.     Above,  corresponding  to  the  upper  margin 


Fig.  26. — Face  of  Embryo,  Fifth  Week.  Front  view.  E,  eye;  IM,  inferior 
maxillary  process  (first  visceral  arch)  joins  in  middle  line  with  its  fellow  of 
the  opposite  side  to  form  the  mandibular  arch  (future  lower  jaw) ;  LN,  lateral 
nasal  process  (outer  extremity  of  the  frontal  process) ;  MN,  middle  nasal 
process  (middle  portion  of  frontal  process);  NN,  nasal  notch  (future  nostril); 
SM,  superior  maxillary  process  (upper  back  part  of  the  first  visceral  arch) ; 
1,  2,  3,  first,  second,  and  third  visceral  arches. 

of  the  oral  pit,  there  appears  a  single  broad  process,  which  is  devel- 
oped by  the  forward  and  downward  growth  of  the  anterior  wall  of 
the  vesicle  of  the  forebrain;  this  is  called  the  frontal  process  or 
frontal  plate,  and  is  really  a  prolongation  of  the  front  wall  of  the 
vesicle  of  the  forebrain;  it  grows  downward  and  plays  a  very  im- 
portant role  in  the  development  of  the  face.  At  this  stage  the  oral 
pit  is  a  five-sided,  deep  fossa,  bounded  above  by  the  frontal  process 
or  frontal  plate,  below  by  the  mandibular  arch  (inferior  maxillary 
processes),  and  upon  each  side  by  the  superior  maxillary  process. 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


89 


The  eyes  are  located  one  upon  either  side  of  the  head,  and  are 
bounded  below  by  the  upper  back  part  of  the  superior  maxillary 
process  and  internally  by  the  outer  border  of  the  frontal  process. 

The  frontal  process,  frontal  plate,  is  broad,  and  consists  of  a 
middle  portion,  the  middle  nasal  process,  and  two  lateral  portions, 
the  lateral  nasal  processes. 


Fig.  27.— Face  of  Embryo,  Fifth  Week.  Front  view.  The  anterior  portion 
of  the  visceral  arches  has  been  cut  away  to  show  the  interior  of  the  mouth 
cavity  (pharynx),  the  wall  of  which  shows  the  visceral  arches  with  interven- 
ing clefts  corresponding  to  those  upon  the  outside.  IM,  cut  surface  of  infe- 
rior maxillary  process;  LN,  lateral  nasal  process;  8M,  superior  maxillary 
process;  1,  2,  3,  4,  cut  surface  of  the  first,  second,  third,  and  fourth  visceral 
arches,  showing  the  corresponding  clefts  between  them.  Between  LN  and 
middle  nasal  process  is  the  nasal  notch  (future  nostril). 


The  middle  nasal  process  is  quite  broad,  and  its  lower  free 
border  is  deeply  notched  in  the  middle.  The  lateral  nasal  process, 
one  on  either  end  of  the  frontal  process,  is  separated  from  the  middle 
nasal  process  by  a  deep  notch,  the  olfactory  groove;  the  floor  of 
each  olfactory  groove  is  intimately  related  with  the  base  of  the 
cerebral  vesicle:    organ  of  smell. 


90 


HEAD  AND  FACE. 


During  the  fourth  week  the  plate  of  tissue  which  forms  the 
floor  of  the  oral  pit  becomes  very  thin,  consisting  only  of  the  epider- 
mic and  endodermic  layers.  It  is  called  the  "rachenhaut  of  Kemak," 
or  the  pharyngeal  membrane,  and  during  this  week  ruptures  and  so 
establishes  a  communication  from  without  with  the  alimentary  tube 
— pharynx. 

Somewhat  later,  about  the  fifth  week,  we  find  that  the  various 
processes  have  approached  each  other,  and  the  appearance  begins 


Fig.  28.— Embryo  about  Fourth  Week,  seen  from  Side, 
arches  with  clefts  between  them. 


1,  2,  3,  4,  visceral 


to  suggest  the  ultimate  conformation  of  the  face.  The  superior 
maxillary  processes  are  nearer  the  middle  line,  the  whole  frontal 
process  is  longer,  and  its  separation  into  a  middle  and  two  lateral 
portions  is  still  more  pronounced  on  account  of  the  increased  depth 
of  the  olfactory  grooves.  The  eyes  are  fairly  well  bounded,  but  are 
still  located  upon  the  side  of  the  head. 

About  the  seventh  week  we  note  that  the  superior  maxillary 
process,  in  part,  has  become  fused  with  the  lateral  nasal  process 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  91 

of  the  frontal  plate;  this  line  of  fusion  corresponds  to  the  position 
of  the  tear-duct.  If  union  does  not  occur  along  this  line,  we  have 
a  so-called  orbito-nasal  or  oblique  facial  cleft.  The  eye  is  entirely 
surrounded  and  is  placed  more  to  the  front  of  the  face.  The  middle 
portion  of  the  frontal  plate,  the  middle  nasal  process,  is  still  notched 
in  the  center  and  broad;  the  extremities  of  this  middle  nasal  process 
have  become  fused  with  the  lowest  and  most  internal  part  of  the 
superior  maxillary  process,  and  by  this  union  the  upper  lip  is  formed 


Fig.  2U.— Embryo  about  Eighth  Week.    Development  of  face  well  advanced. 

and  at  the  same  time  the  olfactory  grooves  are  bounded  below,  and 
are  thus  converted  into  round  openings:  the  nostrils.  If  the  supe- 
rior maxillary  process  and  middle  portion  of  the  frontal  plate, 
middle  nasal  process,  fail  to  unite,  we  have,  as  a  result,  a  cleft  in 
the  lip, — harelip;  this  may  or  may  not  reach  into  the  opening  of 
the  nostril:  i.e.,  may  be  complete  or  incomplete  according  to  the 
extent  to  which  the  parts  have  failed  to  unite. 

The  lower  edge  of  the  superior  maxillary  process  becomes  par- 
tially united  with  the  upper  border  of  the  mandibular  process,  the 


92  HEAD  AND  FACE. 

inferior  maxillary  process,  which  has  also  become  thickened,  and 
in  this  way  the  size  of  the  mouth  is  much  diminished.  If  this  union 
falls  short  of  normal  we  have  a  characteristic  deformity:  macrostoma 
or  transverse  facial  cleft.  The  face,  as  a  whole,  is,  therefore,  at  this 
period  closed  in,  but  the  nostrils  are  still  far  apart,  the  nose  broad, 
and  perfectly  flat  and  directed  forward,  and  the  upper  lip  is  still 
notched  in  the  middle  line.  This  type  of  face  often  persists,  and 
we  then  have  a  peculiar  "pug  face." 

The  openings  for  the  external  auditory  meatus  are  seen  low 
down  upon  either  side  of  the  head. 

The  external  auditory  canal  is  the  remains  of  the  posterior  part 
of  the  first  visceral  cleft:  i.e.,  that  between  the  first  and  second 
arches.  The  margins  of  the  orifice  of  the  auditory  canal  later  be- 
come nodulated;  these  nodules  coalesce,  and  in  this  way  the  auricle 
is  formed.  The  Eustachian  tube  and  the  tympanum  are  the  remains 
of  the  corresponding  first  internal  cleft  (from  pharynx).  The  ear- 
drum represents  the  point  where  the  epiderm,  at  the  bottom  of  the 
outer  cleft,  and  the  endoderm,  at  the  bottom  of  the  inner  cleft,  have 
coalesced  with  each  other. 

At  the  end  of  the  second  month  the  eyes  are  located  toward 
the  front  of  the  face.  The  nose  is  still  broad  and  flat,  although  the 
nostrils  are  rather  closer  together.  The  upper  lip,  representing  the 
middle  portion,  middle  nasal  process,  of  the  frontal  plate,  is  still 
notched  in  the  middle  line.  The  cavity  of  the  mouth  is  fairly  well 
closed  in  by  the  upper  and  lower  lips. 

To  recapitulate:  The  first  visceral  arch  is  eventually  developed 
into  the  inferior  maxillary  bone  and  the  adjoining  soft  parts,  includ- 
ing the  lower  lip  and  the  floor  of  the  mouth,  and  assists  in  the  forma- 
tion of  the  tongue.  The  superior  maxillary  process  of  the  first 
visceral  arch  is  developed  into  the  superior  maxillary  bone  and  the 
adjoining  soft  parts,  including  the  hard  and  soft  palate.  The  frontal 
plate,  its  lateral  portion,  the  lateral  nasal  process,  forms  the  side  of 
the  nose,  including  the  nasal  bones;  its  middle  portion,  the  middle 
nasal  process,  forms  the  bridge  of  integument  between  the  nostrils, 
reaching  from  the  tip  of  the  nose  to  the  upper  lip,  and  the  cartilagi- 
nous and  bony  portions  of  the  nasal  septum  (vomer  and  perpendicular 
plate  of  the  ethmoid);  also  the  middle  portion  of  the  upper  lip  and 
intermaxillary  bone. 

The  intermaxillary  bone  was  first  described  by  the  poet  Goethe. 
It  is  a  small,  wedge-shaped,  bony  process  which  is  attached  to  the 


CONGENITAL  DEFOEMTTIES  OF  THE  FACE.  93 

anterior  end  of  the  vomer  and  fits  into  a  corresponding  triangular 
space  in  the  anterior  part  of  the  hard  palate,  and  carries  the  four 
incisor  teeth.  The  line  of  union  between  this  bone  and  the  palatal 
processes  of  the  superior  maxillary  may  often  be  plainly  seen  in  the 
adult  upper  jaw-bone.  The  anterior  palatine  canal  marks  the  junc- 
tion of  these  parts.  A  non-united,  abnormally  placed  intermaxillary 
bone  often  complicates  harelip. 


Fig.  30.— Face  of  Embryo  about  Eighth  Week.  The  various  processes  that 
go  to  make  up  the  face  have  coalesced,  but  the  embryonal  type  of  the  face  is 
still  well  marked.  Eyes  located  upon  the  side  of  face.  Ears  low  down.  Nose 
flat  and  projecting  forward,  with  nostrils  far  apart.  Upper  lip  still  notched 
in  the  middle. 

Formation  of  the  Palate. — The  superior  maxillary  process  of 
either  side  gives  off,  upon  its  inner  aspect,  a  shelf -like  process:  the 
palate  process.  These  processes  gradually  grow  toward  the  middle 
line  and  unite  with  each  other,  and  thus  form  the  hard  and  soft 
palate,  the  union  taking  place  from  before  backward,  the  uvula  being 
the  last  part  to  unite.    Union  between  the  palatal  processes  is  com- 


94  HEAD  AND  FACE. 

plete  at  about  the  eleventh  week.  With  the  formation  of  the  hard 
and  soft  palate,  the  nasal  cavity  is  separated  from  the  oral,  or  mouth, 
cavity.  Failure  of  union  between  the  palatal  processes  gives  rise 
to  the  various  degrees  of  cleft  palate.  In  front,  where  the  two  halves 
of  the  hard  palate  join  with  the  intermaxillary  bone,  there  are  a 
suture  line  and  the  anterior  palatine  canal. 

The  vomer  and  the  perpendicular  plate  of  the  ethmoid  are  de- 
veloped from  the  middle  portion — the  middle  nasal  process — of  the 
frontal  plate,  and  divide  the  nasal  cavity  into  two  parts.  The  junc- 
tion between  the  lower  border  of  the  vomer  and  the  hard  palate 
occurs  after  the  two  palatal  processes  have  united  with  each  other 
in  the  middle  line.  The  nasal  cavity  opens  in  front  upon  the  face 
through  the  nostrils  and  behind  into  the  pharynx  through  the  poste- 
rior nares. 

The  Teeth. — The  margins  of  the  upper  and  lower  jaw  become 
prominent,  and  in  this  way  form  the  alveolar  processes;  the  epithe- 
lium covering  these  processes  becomes  invaginated, — dips  down  into 
the  substance  of  the  processes, — and  from  this  the  teeth  are  formed. 

The  floor  of  the  mouth  is  developed  from  the  first  visceral  arch. 

The  Tongue. — The  tongue  is  developed,  its  anterior  portion  from 
the  first  arch  and  its  posterior  portion  from  the  second  and  third 
arches.  The  anterior  part — the  body  and  tip — is  developed  from  a 
tubercle  which  appears  in  the  front  part  of  the  mouth  at  the  junction 
of  the  two  halves  of  the  first  arch.  The  back  part,  the  root,  is  devel- 
oped in  the  back  part  of  the  mouth  from  the  wall  of  the  pharynx, 
from  two  tubercles  at  the  junction  of  the  second  and  third  arches. 
These  two  parts  of  the  tongue,  the  anterior  and  the  posterior,  become 
joined,  the  line  of  union  being  indicated  by  the  V-shaped  row  of 
papillas  upon  the  dorsum  of  the  adult  tongue.  At  the  apex  of  the  V 
there  is  a  dimple,  the  foramen  caecum,  which  indicates  the  point  of 
junction  of  the  parts  of  which  the  tongue  is  formed.  As  the  tongue 
is  developed,  it  increases  rapidly  in  size,  occupying  the  mouth  cavity 
and  projecting  up  into  the  future  nasal  cavity.  As  the  palatal 
processes  grow  inward  to  meet  each  other  in  the  middle  line,  how- 
ever, the  tongue  is  gradually  forced  down  into  the  mouth  cavity 
proper,  where  it  belongs. 

Deformities  of  the  Face. — These  consist  of  abnormal  clefts  and 
atresias,  which  may  be  partial  or  complete. 

Clefts  are  due  to  the  entire  or  partial  absence  of  normal  union 
between  the  original  embryonal  processes  by  whose  coalescence  the 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


95 


face  is  formed.  Atresias  are  caused,  on  the  other  hand,  hy  excessive 
union,  beyond  the  normal,  between  these  processes,  and  as  a  result 
we  get  a  partial  or  complete  closure  of  the  facial  orifices:  mouth, 
nostrils,  and  eyes.  Still  further,  the  union  between  the  processes 
may  occur  to  its  normal  extent,  but  the  lines  of  union  may  remain 
permanently  marked  by  cicatricial  seams  or  irregular  tags  and 
nodules. 

The  failure  of  the  embryonal  processes  properly  to  coalesce, 


Fig.  SI.— Diagram  of  Congenital  Facial  Clefts.  Shaded  portions  indicate 
the  location  of  the  different  congenital  fissures.  HL,  harelip;  IM,  inferior 
maxillary  process;  LN,  *,  lateral  nasal  process  of  frontal  plate;  LN,  lateral 
nasal  cleft;  M.N.,  middle  nasal  process  of  frontal  plate;  OF,  oblique  facial 
cleft;  8M,  superior  maxillary  process;  TF,  transverse  facial  cleft;  *,  lower 
part  of  lateral  nasal  process  which  takes  part  in  the  formation  of  the  upper 
lip,  but  not  of  its  red  border;  the  free  red  margin  of  the  lip  is  formed  by  the 
union  of  the  lower  part  of  the  middle  nasal  process  (MN)  and  the  lower 
part  of  the  superior  maxillary  process  (SM). 


with  the  resulting  clefts,  is  really  due  to  the  incomplete  develop- 
ment of  the  processes  themselves;  they  are  deficient:  i.e.,  too  small 
to  meet  each  other,  and  hence  the  clefts.  The  clefts  vary  in  degree 
from  narrow,  incomplete  fissures  to  widely  gaping  spaces.  The  mar- 
gins of  the  clefts  may  be  smooth  or  they  may  be  irregular  and  marked 
by  nodular  processes,  tags,  etc. 

The  congenital  deformities  of  the  face  may  be  divided  into  two 
general  groups: — 


96  HEAD  AND  FACE. 

(A)  Those  in  which  the  frontal  plate  or  process  is  concerned. 
Under  this  heading  we  have: — 

1.  Lateral  clefts  of  the  upper  lip  and  the  alveolar  process;  clefts 
of  the  palate  may  also  be  conveniently  included  in  this  group. 

2.  Median  clefts  or  notches  of  the  upper  lip  and  deformities  of 
the  nose. 

3.  Notching  of  the  wing  of  the  nose. 

4.  Oblique  facial  fissures,  etc. 

(B)  Those  in  which  the  first  visceral  arch  is  involved.  In  this 
group  we  have: — 

1.  Transverse  facial  fissures. 

2.  Median  fissures  of  the  lower  lip,  lower  jaw,  and  tongue. 

3.  Deformities  of  the  lower  jaw. 

Deformities  in  Which  the  Frontal  Plate  is  Concerned.  Latekal 
Clefts  of  the  Upper  Lip  and  of  the  Alveolae  Process  and 
Cleft  Palate. — Clefts  of  the  upper  lip  and  alveolar  process  depend 
upon  imperfect  union  of  the  middle  portion,  middle  nasal  process, 
of  the  frontal  plate  with  the  corresponding  lower  portion  of  the 
superior  maxillary  processes:  to  failure  of  the  intermaxillary  bone 
and  its  accompanying  soft  parts  to  unite  with  the  adjoining  portion 
of  the  face.  These  clefts  are  always  lateral  and  may  be  present  on 
one  or  both  sides.  Clefts  of  the  palate  (hard  and  soft)  depend  upon 
non-union,  partial  or  complete,  of  the  palatal  process  of  the  superior 
maxillary  process  of  either  side  with  each  other.  These  clefts  are 
median  when  the  processes  of  both  sides  are  at  fault.  If  the  palatal 
process  of  one  side  only  is  involved,  the  fissure  will  be  present  upon 
the  corresponding  side  of  the  middle  line,  the  palatal  process  of  the 
other  side  being  joined  with  the  lower  border  of  the  vomer,  thus 
shutting  off  the  nasal  cavity,  on  that  side,  from  the  mouth. 

If  union  has  failed,  on  both  sides,  between  the  middle  process  of 
the  frontal  plate,  the  middle  nasal  process,  and  the  corresponding  part 
of  the  superior  maxillary  process  of  either  side  (double  harelip  and  fis- 
sure of  the  alveolar  process)  and  between  the  palatal  processes  of  the 
superior  maxillary  processes  of  either  side  (cleft  of  the  hard  and  soft 
palate),  we  have  the  most  extreme  variety  of  this  group  of  deformi- 
ties. There  are  found  all  degrees  of  this  variety  of  deformity  from 
this  exaggerated  form  down  to  a  mere  notching  of  the  upper  lip 
(incomplete  harelip)  or  bifurcation  of  the  uvula. 

Harelip. — This  condition  may  be  incomplete  or  complete. 

Incomplete  harelip  consists  in  a  vertical  notch  in  the  free  mar- 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  97 

gin  of  the  upper  lip.  It  is  located  to  one  side  of  the  middle  line 
between  the  middle  segment  and  the  lateral  segment  of  the  lip.  It 
varies  in  depth  from  a  barely  noticeable  notch  to  a  deep  fissure 
which  may  extend  almost  through  the  entire  lip,  leaving  but  a  nar- 
row bridge  of  integument  separating  the  angle  of  the  notch  from 
the  nostril. 

In  complete  harelip  the  fissure  extends  all  the  way  through  the 
upper  lip  into  the  nostril.  It  may  be  associated  with  cleft  of  the 
alveolar  process  and  with  cleft  palate.  The  nose  is  apt  to  be  un- 
usually broad  and  flattened,  the  wing  of  the  nose,  on  the  side  corre- 
sponding to  the  cleft,  being  carried  outward  away  from  the  middle 
line.    These  deformities  may  involve  one  or  both  sides.    If  double, 


Fig.  32.— Double  Complete  Harelip. 

those  of  the  two  sides  may  differ  from  each  other,  the  fissure  on  one 
side  may  be  complete,  that  of  the  other  side  incomplete,  or  those  of 
both  sides  may  be  complete.  They  may  be  associated  with  cleft  of 
the  alveolar  process  and  with  cleft  palate,  the  intermaxillary  bone 
often  being  small  and  misplaced  forward.  The  entire  middle  seg- 
ment of  the  lip  may  be  absent,  together  with  the  intermaxillary  bone 
and  the  vomer.  In  this  case  the  upper  lip  shows  a  broad,  median 
space,  which  opens  into  the  nasal  cavity. 

Cleft  of  the  Alveolar  Process. — With  harelip,  as  already  men- 
tioned, there  may  also  be  present  a  cleft  of  the  alveolar  process, 
and  this  may  vary  from  a  narrow,  incomplete  fissure  to  a  broad,  open 
space;  it  may  be  unilateral  or  double,  and  is  usually  associated  with 


98  HEAD  AND  FACE. 

cleft  palate.  If  there  is  no  cleft  of  the  hard  palate,  the  cleft  of  the 
alveolar  process  terminates  at  the  anterior  palatine  foramen:  the 
meeting  point  of  the  palatal  process  of  either  side  and  the  inter- 
maxillary bone.  If  the  cleft  in  the  alveolar  process  involves  both 
sides,  the  intermaxillary  bone,  which  is  continuous  with  the  front 
of  the  vomer,  may  be  placed  forward  in  advance  of  the  rest  of  the 
alveolar  process,  especially  if  cleft  palate  is  also  present;  so  that  it 
and  the  corresponding  portion  of  the  npper  lip  seem  to  be  suspended 
from  the  point  of  the  nose.  In  this  case  the  lower  tegumentary  part 
of  the  septum  of  the  nose  is  absent,  the  soft  parts  which  represent 
the  middle  part  of  the  lip  being  continued  directly  with  the  tip  of 
the  nose.    This  advancement  of  the  intermaxillary  bone  is  due  to  the 


Pig.  33.— Harelip  with  (A)  Advanced  Intermaxillary  Portion. 

unrestricted  forward  growth  of  the  vomer,  which  is  not  inhibited  as 
is  normally  the  case  when  it  is  joined  to  the  palatal  processes.  If 
the  cleft  is  confined  to  one  side  of  the  alveolar  process  and  the  hard 
palate,  the  intermaxillary  bone,  as  it  is  carried  forward  by  the  growth 
of  the  vomer,  is  apt  to  become  markedly  twisted  upon  its  long  axis, 
so  that  its  anterior  surface,  instead  of  being  directed  forward,  looks 
almost  directly  toward  the  normal  side  of  the  face,  presenting  its 
prominent  sharp  lateral  edge  anteriorly.  The  intermaxillary  seg- 
ment may  be  entirely  absent,  as  already  mentioned. 

Cleft  Palate. — The  presence  of  a  longitudinal  fissure  which  may 
involve  the  hard  or  soft  palate  or  both.  It  is  caused  by  a  failure 
of  the  palatal  processes  of  the  superior  maxillary  processes  to  meet 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  99 

in  the  middle  line  and  coalesce.  In  these  cases  the  base  of  the 
skull  may  be  unusually  broad  and  the  pterygoid  processes  unusually 
far  apart. 

Cleft  of  the  Hard  Palate. — This  may  be  unilateral  or  double. 
If  one-sided,  the  palatal  process  of  the  normal  side  is  seen  to  be 
united  with  the  lower  border  of  the  vomer,  shutting  off  that  side 
of  the  nasal  cavity  from  the  mouth,  while  upon  the  affected  side 
the  palatal  process  is  deficient  and  falls  short  of  meeting  its  fellow 
of  the  opposite  side,  and  there  is  thus  left  an  opening  which  leads 
into  the  corresponding  half  of  the  nasal  cavity.  In  double  cleft 
palate  both  palatal  processes  are  deficient,  and  the  lower  free  edge 
of  the  vomer  may  be  seen  between  the  separated  edges  of  the  cleft. 


Fig.  34.— Double  Cleft  Palate  with  Advanced  Intermaxillary  Portion  (IM) 
Carrying  the  Sockets  of  Two  Incisor  Teeth.  V,  vomer  (septum  of  the 
nose). 

Usually  the  lower  border  of  the  vomer  does  not  reach  low  enough 
to  present  itself  in  the  fissure  between  the  edges  of  the  cleft,  and 
the  cleft  thus  has  the  appearance  of  a  median  cleft  when  it  is,  in 
reality,  a  bilateral,  or  double,  cleft. 

At  times  we  may  find  the  palatal  processes  of  either  side  prop- 
erly united  with  each  other,  but  the  vomer  fails  to  grow  down  suffi- 
ciently far  to  articulate  with  them,  and  there  is  thus  left  a  space 
below  the  lower  border  of  the  vomer  through  which  the  two  sides  of 
the  nasal  cavity  communicate  with  each  other.  It  should  be  remem- 
bered that  the  vomer  does  not  play  any  part  in  the  formation  of  the 
hard  palate. 

Cleft  of  the  hard  palate  ends  anteriorly,  either  at  the  anterior 


100  HEAD  AND  FACE. 

palatine  foramen,  which  marks  the  point  of  junction  between  the 
intermaxillary  bone  and  the  palatal  processes  of  the  superior  maxil- 
laries,  or  else  it  is  combined  with  a  single  or  double  cleft  of  the 
alveolar  process  and  harelip.  It  usually  ends,  posteriorly,  in  cleft 
of  the  soft  palate. 

In  cleft  palate,  especially  if  double,  the  forward  growth  of  the 
vomer  is  unrestricted  on  account  of  its  not  being  joined  to  the 
palatal  processes,  and  by  this  forward  growth  the  intermaxillary 
bone  and  its  corresponding  soft  parts  may  be  carried  forward  beyond 
the  line  of  the  alveolar  processes,  the  intermaxillary  bone  often  being 
bent  upward  or  twisted  upon  its  long  axis  (see  Fig.  34).  This  ad- 
vancement of  these  parts  adds  very  much  to  the  difficulty  of  cor- 
recting the  deformity. 

Cleft  of  the  Soft  Palate. — The  fissure  extends  from  the  tip  of  the 
uvula  for  a  varying  distance  into  the  soft  palate.  It  may  be  simply 
a  bifurcation  of  the  uvula,  but,  as  a  rule,  it  extends  all  the  way 
through  the  soft  palate  as  far  as  the  posterior  border  of  the  hard 
palate  or  for  some  distance  into  the  hard  palate.  It  may  be  com- 
bined with  a  lateral  or  double  cleft  of  the  hard  palate.  As  is  the 
case  with  cleft  of  the  hard  palate,  there  is  not  only  a  simple  lack 
of  union  between  the  two  halves  of  the  palate,  but  an  actual  defi- 
ciency of  tissue  which  prevents  the  parts  from  meeting  and  coalescing 
in  the  middle  line,  and  this  fact  is  important  in  considering  the 
operative  treatment  of  this  condition. 

With  the  exaggerated  forms  of  cleft  palate  there  is  frequently 
associated  imperfect  development  of  the  middle  nasal  process  of  the 
frontal  plate  or  it  may  be  entirely  absent:  the  intermaxillary  bone 
may  be  absent,  with  or  without  absence  of  the  vomer.  If  the  inter- 
maxillary bone,  etc.,  are  absent,  we  have  a  median  cleft  of  the  upper 
lip,  or,  better,  a  double  harelip  with  absence  of  its  middle  segment; 
and  this  condition  is  usually  associated  with  a  broad  cleft  in  the 
hard  and  soft  palate,  and  the  nose  may  be  soft  and  flattened,  on 
account  of  the  absence  of  the  nasal  septum,  etc.  This  condition 
is  apt  to  be  accompanied  with  defective  cerebral  development. 

Median  Clefts  and  Notches  of  the  Upper  Lip. — These  de- 
formities depend  upon  exaggeration  and  persistence  of  the  embryonal 
notch  of  the  middle  portion,  the  middle  nasal  process,  of  the  frontal 
plate  and  failure  of  the  nostrils  to  approach  each  other.  These 
defects  are  much  less  frequent  than  the  preceding.  There  may  be 
simply  a  notch  or  fissure  in  the  middle  of  the  upper  lip  reaching  part 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  101 

way  through,  or  this  may  be  combined  with  a  grooving  or  furrow  upon 
the  point  and  dorsum  of  the  nose  and  a  wide  separation  between 
the  nostrils.  This  condition  may  be  so  pronounced  that  the  nose 
appears  to  consist  of  two  halves  completely  separated  from  each 
other  and  each  containing  one  nostril.  Instead  of  this  extreme 
degree  of  deformity  the  nose  may  be  simply  flattened,  the  bridge  de- 
pressed, the  nostrils  far  apart  and  looking  directly  forward:  "dog 
nose."  The  fissure  in  the  upper  lip  instead  of  simply  notching  the 
lip  may  extend  completely  through  the  whole  lip  and  into  the  inter- 
maxillary bone.  This  variety  of  deformity  may  also  be  represented 
by  a  fistula  of  the  tip  or  dorsum  of  the  nose. 

Lateral  Nasal  Clefts. — These  occur  with  or  without  harelip 
and  cleft  palate;  the  notch  or  fissure  involves  the  wing  of  the  nose. 
If  they  extend  upward  for  a  considerable  distance  through  the  side 


Fig.  35.— Oblique  Facial  Cleft  Extending  into  the  Temporo-frontal  Region. 

of  the  nose,  they  terminate  above,  not  in  the  inner  canthus,  but  to 
the  inner  side  of  the  inner  corner  of  the  eye;  they  represent  the 
embryonal  notch  between  the  middle  and  lateral  nasal  processes  of 
the  frontal  plate.  Fissures  of  the  side  of  the  nose,  that  resemble 
these,  but  terminate  above  in  the  inner  canthus  of  the  eye,  are 
varieties  of  oblique  facial  clefts. 

Oblique  Facial  Clefts. — Failure  of  normal  union  between  the 
lateral  process  of  the  frontal  plate  and  the  superior  maxillary  process 
of  the  first  visceral  arch.  They  correspond  to  the  embryonal  orbito- 
nasal line  of  coalescence.  These  deformities  may  be  very  extensive 
or  slight:  one-sided  or  double.  They  commence  below  at  the  edge 
of  the  upper  lip,  and,  after  splitting  this  at  the  usual  harelip  site, 
extend  upward  through  the  cheek,  alongside  of  the  wing  of  the  nose, 


102 


HEAD  AND  FACE. 


not  into  the  nostril,  like  harelip,  and  terminate  above,  at  the  lower 
margin  of  the  eye  (lower  lid)   or  inner  canthus.  They  may  extend 


Fig.  36.— Incomplete  Oblique  Facial  Cleft.  The  edge  of  the  upper  lip  13 
notched  and  a  cicatricial  lme  extends  across  the  cheek  to  the  lower  eyelid, 
which  is  everted. 

beyond  the  orbit,  from  its  outer  corner,  upward  and  outward  into 
the  fronto-temporal  region  of  the  skull.     They  vary  from  a  narrow 


Fig 


Transverse    Facial    Cleft. 


fissure  or  incomplete  notch  to  a  wide,  gaping  fissure,  between  the 
edges  of  which  is  the  eyeball.     This  class  of  deformity  is  frequently 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC.      103 

represented  in  its  'simplest  form  by  a  notch  or  coloboma  of  the  lower 
or  upper  eyelid.  Instead  of  a  fissure,  this  deformity  may  be  repre- 
sented by  a  cicatricial,  nodulated  seam,  indicating  the  orbito-nasal 
junction. 

Deformities  in  Which  the  First  Visceral  Arch  is  Concerned. 
Transverse  Facial  Clefts,  etc. — These  are  due  to  a  failure  of 
the  inferior  maxillary  process  of  the  first  visceral  arch  and  its  supe- 
rior maxillary  process  to  coalesce  to  the  normal  extent.  This  de- 
formity may  be  unilateral  or  double.  The  cleft  extends  from  the 
corner  of  the  mouth  outward  through  the  cheek  and  exposes  the 
teeth:  macrostoma.  If  the  reverse  of  this  process  occurs,  we  may 
have  a  mouth  so  small  as  to  require  surgical  interference:  micro- 
stoma. 

Median  Clefts  of  the  Lower  Lip,  Lower  Jaw,  and  Tongue. 
— These  conditions  are  very  rare.  They  are  due  to  failure  of  the 
two  halves  of  the  first  visceral  arch  (mandibular  processes)  to  unite 
with  each  other  in  the  middle  line.  They  vary  from  a  slight  notch- 
ing of  the  lower  lip,  in  the  middle  line,  to  a  complete  separation 
through  the  lower  lip,  the  lower  jaw  at  the  symphysis,  and  the 
tongue.  The  tongue,  by  itself,  may  be  split  or  absent  or  bound  down 
to  the  floor  of  the  mouth  or  adherent  to  the  side  of  the  cheek,  etc. 

The  lower  jaw  may  be  imperfectly  developed,  rudimentary,  etc. 
It  may  be  split  in  the  middle  line  or  there  may  be  absence  of  the 
condyles,  etc.  As  the  formation  of  the  face  advances  the  jaw  is 
gradually  protruded  forward,  and,  if  arrested,  we  have,  as  a  result, 
the  receding  chin,  etc. 

OPERATIONS  FOR  HARELIP  AND  CLEFT  PALATE,  ETC. 

Operations  for  Harelip. — In  speaking  of  harelip — if  single — the 
flap  corresponding  to  the  angle  of  the  mouth  is  called  the  lateral 
flap,  or  segment,  and  the  other,  the  middle;  if  the  harelip  is  double, 
one  speaks  of  the  middle  segment  and  two  lateral  segments,  the  right 
and  the  left. 

Koenig  advocates  early  operation,  within  a  few  days  after  birth. 
Trendelenburg  advises  delaying  the  operation  until  later,  operating 
between  the  third  and  sixth  months,  and,  if  very  complicated,  waiting 
still  longer.  Trendelenburg  claims  that  the  difficulty  in  nourishing 
the  children  is  not  a  good  ground  for  early  operation;  that  children, 
even  with  a  cleft  palate  in  addition  to  the  harelip,  can  feed  from 


104  HEAD  AND  FACE. 

a  bottle  if  it  is  provided  with  a  nipple  attached  to  the  neck  of  the 
bottle  itself,  and  especially  if  the  child  is  assisted  by  the  nurse 
holding  the  bottle.  If  the  child  is  able  to  take  the  breast  it  will 
not  be  necessary  to  change  to  the  bottle  after  operation  and  the 
breast  nursing  may  still  be  continued.  At  the  time  of  operation  the 
child  should  be  free  from  intestinal  trouble,  and  there  should  be 
little  or  no  nasal  catarrh. 

For  children  under  one  year  no  anaesthetic  is  necessary;  for 
older  children  one  may  use  incomplete  chloroform  anaesthesia. 

The  child  should  be  wrapped  in  a  blanket  in  such  a  way  that 
the  arms  and  legs  are  confined  and  then  held  upright  in  the  arms 
of  a  nurse  who  sits  opposite  the  operator.  The  child's  head  is 
steadied  by  an  assistant,  who  thrusts  the  head  a  little  forward  to 
prevent  the  blood  entering  the  mouth  during  the  operation. 

The  instruments  that  are  required  consist  of  a  sharp,  narrow- 
bladed  knife  with  a  sharp  point,  several  tenacula,  mouse-tooth 
forceps,  and  narrow-bladed  sharp-edged  scissors.  The  steps  of  the 
operation  consist  in  freshening  the  edges  of  the  cleft  and  suturing. 
In  freshening  the  edges  one  should  cut  with  a  view  to  providing 
broad,  raw  surfaces  for  apposition;  they  should  be  cut  somewhat 
obliquel}r,  and  more  taken  away  from  the  skin  than  from  the  mu- 
cous surface.  During  this  step  of  the  operation  the  hemorrhage 
may  be  controlled  by  an  assistant,  who  compresses  either  segment 
of  the  lip  between  the  finger  and  thumb,  or  a  clamp  may  be  applied 
on  either  side  of  the  defect  in  the  lip  (Trendelenburg).  With  the 
mouse-tooth  forceps  the  edge  of  the  defect  is  seized  and  transfixed 
with  a  knife,  and  the  incision  made  with  a  sawing  motion  and  with 
deliberation.  In  order  to  bring  the  raw  surfaces  into  apposition  it 
is  occasionally  necessary  to  liberate  the  flaps  by  cutting  them  free 
from  their  attachment  to  the  deeper  adjoining  parts :  the  alveolar 
process  and  anterior  surface  of  the  superior  maxilla. 

As  suture,  several  harelip  pins  may  be  used,  each  with  a  figure-of- 
eight  coil  of  silk  floss.  Without  these  pins,  or  in  addition  to  them,  one 
may  unite  the  raw  surfaces  with  one  to  three  heavier  silk  sutures  car- 
ried in  a  straight  or  curved  needle.  These  should  penetrate  deep 
into  the  substance  of  the  lip,  clown  to,  but  not  through,  the 
mucous  membrane,  and  should  take  a  good  hold.  Between  these 
the  skin  and  mucous  membrane  are  brought  accurately  together, 
edge  to  edge,  with  a  number  of  superficial  sutures  of  rather  finer 
silk. 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


105 


Operations  for  Incomplete  Harelip.  Simple  Freshening  of 
the  Opposing  Edges  and  Suture. — This  plan  would  not  answer 
even  for  incomplete  harelip,  since  a  notch  would  remain  which 
would  increase  with  time  as  the  sear  contracts,  especially  if  the 
cleft  is  deep. 


? 


I     (i 


Fig.  38.— Simple  Paring  of  the  Edges  of 
the  Notch  for  Incomplete  Harelip. 


Fig.  39.— Imperfect  Result  After  Sim- 
ple Paring  and  Suture,  Showing  the 
Notch  Still  Present. 


Von  Graefe  proposed  a  very  simple  method  to  increase  the 
length  of  the  apposed  edges  of  the  freshened  surfaces.  This  method 
will  answer,  however,  only  for  the  very  incomplete  defects,  and  not 
for  wide  or  complete  splits.  It  consists  in  paring  the  edges  of  the 
notch  by  making  a  circular  incision,  which  arches  over  the  corner  of 
the  notch. 


D      fl 


Fig.  40. — Von  Graefe  Method  of  Paring 
an  Incomplete  Harelip  so  as  to  Increase 
the  Length  of  the  Raw  Apposed  Edges. 


Fig.  41.— Result  After  Suturing. 


Nelaton  Method. — Without  removing  any  tissue,  an  incision 
is  made  through  the  substance  of  the  lip,  around  the  corner  of  the 
notch  and  parallel  with  its  edges,  and  after  converting  this  incision 
into  a  vertical  one  its  edges  are  united  with  several  interrupted 
stitches. 


106 


HEAD  AND  FACE. 


Fig.  42. — Nelaton  Opera-  Fig.  43.— Incision  Con- 
tion  for  Incomplete  Hare-  verted  into  a  Perpendicu- 
lip.     Line  of  incision.  lar,  Ready  for  Suture. 


After 


Malgaigne  proposed  to  close  the  defect,  especially  where  the 
defect  is  considerable,  by  making  use  of  flaps  in  addition  to  fresh- 
ening the  edges.  In  his  operation  the  tissue  is  removed  from  the 
angle  of  the  notch  only,  the  second  part  of  the  operation  consisting 
in  the  formation  of  flaps  by  simply  cutting  into  the  substance  of 
the  lip  along  either  side  of  the  defect,  commencing  near  the  angle 
and  cutting  toward  the  red  border  of  the  lip.     The  base  of  the  flap 


Fig.  45.— Malgaigne  Oper-  Fig.      46.— Flaps     Turned 

ation  for  Incomplete  Hare-  Down,    Ready    for    Suture. 
lip.     Paring  and  formation 
of  flaps. 


''trarrmrrff'' 

Fig.       47.— Result      After 
Parts  have  been  Sutured. 


should  be  no  thicker  than  the  red  of  the  lip;  otherwise  it  is  very 
difficult  to  turn  it  down.  The  tongues  of  tissue  thus  marked  out 
are  turned  down  and  sutured  together,  with  the  result  that  the  cleft 
is  not  only  filled  in,  but  a  little  tongue  of  tissue  is  left  projecting 
beyond  the  free  line  of  the  lip  to  allow  for  future  retraction. 

The  objection  to  this  operation  is  that,  on  account  of  the  con- 
siderable torsion  to  which  the  flaps  are  subjected,  their  nourishment 
is  uncertain  and  they  may  become  gangrenous,  especially  in  very 
young  children. 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


107 


Mieault's  operation  is  an  improvement  on  Malgaigne's.  Only 
one  flap  is  made,  and  that  is  taken  from  the  edge  of  the  lateral 
segment.  The  flap  which  is  thus  formed  is  sutured  to  the  freshened 
edge  of  the  middle  segment.  This  single  flap  is  not  likely  to  become 
gangrenous  as  is  the  Malgaigne,  because  it  is  not  necessary  to  turn 
it  down  so  far,  and,  secondly,  because  its  base  may  be  made  suffi- 
ciently broad  to  include  the  coronary  vessels.  In  forming  the  flap 
a  single  cut  is  made  into  the  substance  of  the  lip  proper,  striking 
well  above  the  red  margin  so  that  the  base  of  the  flap  corresponds 
to  the  lower  third  of  the  breadth  of  the  lip.  This  is  a  very  satis- 
factory operation.  It  has  been  modified  by  Simon,  Koenig,  Esmarch, 
Hagedorn,  and  others. 


„#■*'<( 


Fig.    48.— Mirault    Opera-     Fig.    49. 
ation  for  Incomplete  Hare- 
lip.    Paring  and  formation 
of  one  flap. 


-  Parts   ready   for 
Suture. 


Fig.   50.— Result  After  Su- 
ture. 


Operations  for  Complete  Harelip.  —  Cases  in  which  the  split 
extends  through  the  entire  width  of  the  lip. 

In  these  cases  it  is  not  only  necessary  to  freshen  and  prepare 
the  edges  for  suture,  but  one  must,  in  addition,  detach  the  soft 
parts,  in  order  that  the  raw  surfaces  may  be  brought  together  and 
sutured;  one  must  unite  the  whole  width  of  the  lip  from  the  nasal 
opening  down  to  its  free  border,  and  further  strive  to  correct  the 
accompanying  nasal  deformity.  It  usually  suffices  to  separate  the 
outer  or  lateral  segment,  that  nearer  the  corner  of  the  mouth,  from 
its  attachment  to  the  superior  maxillary  bone.  Only  in  extreme 
cases  does  it  become  necessary  to  detach  the  other  flap  as  well.  To 
separate  the  flap  from  the  underlying  bone  one  seizes  its  edge  with 
a  mouse-tooth  forceps,  and  draws  it  inward  toward  the  middle  line, 
and  forward,  away  from  its  attachment  to  the  bone.  In  this  way  the 
fold  of  the  mucous  membrane  which  attaches  the  lip  to  the  gum  is 


108 


HEAD  AND  FACE. 


put  upon  the  stretch,  and  may  be  incised  with  the  edge  of  the  knife, 
cutting  toward  the  bone  (superior  maxillary).  This  incision  is  car- 
ried sufficiently  far  and  deep  to  liberate  the  lateral  flap  and  the 
corresponding  side  of  the  nose  and  to  allow  of  the  parts  being  readily 


Fig.  51. — Wellenschnitt  for  Complete  Harelip.  Incision  carried  around  the 
alse  of  the  nose  in  order  to  liberate  the  segments.  Formation  of  flaps  by  in- 
cision into  each  segment. 

apposed  without  tension.  Hemorrhage  from  this  incision  is  often 
considerable,  especially  if  it  is  necesary  to  cut  deep,  and  this  is 
given  as  one  of  the  reasons  for  waiting  in  these  cases,  at  any  rate, 
until  the  third  or  fourth  month  (Trendelenburg).  The  hemorrhage, 
however,  usually  ceases  when  the  sutures  are  inserted  and  compres- 
sion applied;  still,  any  spurting  vessels  that  are  to  be  seen  should  be 
clamped  and  ligated  with  fine  catgut. 

Occasionally,  in  order  to  free  the  flap  sufficiently  it  may  be 
necessary  to  make  an  incision  around  the  wing  of  the  nose;    this, 


Fig.  52.— Hagedorn  Oper- 
ation for  Single  Complete 
Harelip.     Lines  of  incision. 


Fig.  53.— Parts  Freshened 
and   Ready    for    Suture. 


'••■rf,  fr/st'' 

Fig.  54.— Result  After  Su- 
ture. 


however,  is  but  seldom  necessary  (Dieffenbach's  Wellenschnitt).  The 
Mirault  or  the  Hagedorm  operation  is  usually  done  for  this  condition 
of  complete  harelip. 

Hagedorn's  operation  consists  in  paring  away  the  edges  of  each 
flap,  first  from  the  margin  of  the  lateral  flap, — that  nearer  the  angle 
of  the  mouth, — and  then  from  the  margin  of  the  other  flap.     A 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC.  109 

horizontal  incision  is  then  made  into  the  substance  of  the  lateral 
flap  and  an  oblique  one  into  the  median  flap.  With  a  scissors, 
the  long  strips  of  vermilion  border  which  have  been  pared  away  from 
the  edges  of  the  flaps  are  snipped  off.  When  the  parts  are  sutured 
there  is  left  a  little  process  hanging  from  the  edge  of  the  lip;  this 
retracts  in  time. 

Operation  for  Single,  Complete  Harelip  Associated  with  Cleft  of 
the  Alveolar  Process  and  Advancement  of  the  Intermaxillary  Bone. 
— In  these  cases  the  intermaxillary  bone,  besides  being  misplaced, 
may  be  rotated  upon  its  long  axis  in  such  a  way  that  it  presents, 
anteriorly,  a  prominent,  sharp  edge,  which  would  greatly  interfere 
with  the  healing  process. 

Under  these  circumstances  it  becomes  necessary  to  place  the 
bone  in  its  natural  position.  An  effort  should  be  made,  by  twisting 
it  upon  its  long  axis,  to  set  it  square  so  that  its  sharp,  lateral  edge 
will  not  project  under  the  suture  line.  If  necessary,  with  the  bone 
forceps  or  the  chisel  the  process  may  be  separated  forcibly  from  its 
attachment  to  the  alveolus  and  brought  into  position  by  rotating  it 
partly  upon  its  long  axis.  The  vomer,  to  the  front  of  which  the 
intermaxillary  is  joined,  may  prevent  this  replacement,  and  then  it 
may  be  wise  to  resect  the  prominent  edge  of  the  intermaxillary  with 
a  chisel  or  rongeur,  but  if  we  do  this  we  lose  an  incisor  tooth.  These 
measures  complicate  the  operation  and  occasion  considerable  hemor- 
rhage, and  therefore  it  is  often  well,  with  this  condition,  to  defer  the 
operation  in  very  young  children.  After  the  intermaxillary  bone 
has  been  reduced  or  resected,  closure  of  the  split  in  the  lip  may  be 
accomplished  by  any  of  the  methods  described  above. 

Operation  for  Double  Harelip  without  a  Prominent  Advanced 
Intermaxillary  Bone. — The  middle  segment  is  always  found  to  be 
too  short  to  take  part  in  the  formation  of  the  free  border  of  the  lip, 
but  it  may  be  used  to  form  the  middle  portion  of  the  lip.  From  the 
whole  of  the  middle  segment  and  from  each  lateral  segment  in  part, 
the  mucous  membrane  edge  is  trimmed  away,  and  a  Malgaigne  flap 
then  made  from  the  edge  of  each  lateral  segment.  One  side  may  be 
done  at  a  sitting,  or  one  may,  by  freshening  the  lateral  margins  of 
the  middle  segment  and  the  corresponding  margins  of  the  lateral 
segments,  transform  the  condition  into  a  double,  incomplete  hare- 
lip and  later  do  a  second  operation  to  correct  this.  If  the  nose  is 
flattened  and  the  alae  spread  out,  one  should  try  to  correct  this 
deformity  at  the  same  time  by  separating  the  lateral  segments  of 


110 


HEAD  AND  FACE. 


the  lips  and  the  sides  of  the  nose  from  their  deep  attachments. 
Instead  of  the  Malgaigne,  a  double  Hagedorn  may  be  done  for  this 
condition. 

Operation  for  Double  Harelip  with  Prominent  Advanced  Inter- 
maxillary Bone. — This  may  be  remedied  by  resecting  the  bony  part 
of  the  prominent  intermaxillary  portion,  leaving  the  soft  parts  to 
assist  in  making  the  lip.  The  middle  segment  may  be  placed  very  far 
forward  upon  or  near  the  point  of  the  nose,  in  which  case  the  cuta- 


''''//rsfs/r/0f'' 


''s/y/r/rs//' 


Fig.       55.— Double       Mai-        Pig.      56.— Flaps      Turned 
gaigne      Operation      for      a    Down     Ready    for     Suture. 
Double    Complete    Harelip. 
Paring  of   edges   of   defects 
and  formation   of   flaps. 


'"''///frrv/f/'/rr*'' 


Fig.  57.— Result  After  Su- 
ture. 


•Vftfff"'' 


Fig.  58.— Hagedorn  Oper- 
ation for-  Complete  Double 
Harelip.  Paring  and  for- 
mation of  flaps. 


'""frffrrtfi''' 


Fig.  59.— Parts  Ready  for 
Suture. 


Fig.  60.— Result  After  Su- 
ture. 


ncous  part  of  the  septum  of  the  nose  is  absent  (see  Fig.  33).  Under 
these  circumstances  the  soft  parts  of  the  middle  segment  of  the  lip 
must  be  used  to  make  the  tegumentary  part  of  the  nasal  septum,  and 
then  the  whole  lip  must  be  formed  from  the  two  lateral  segments 
without  the  assistance  of  the  middle  portion.  It  may  be  necessary 
to  liberate  the  flaps  by  separating  them  from  the  alveolar  process  of 
the  superior  maxillary  or,  in  addition  to  this,  by  making  an  incision, 
upon  either  side,  around  the  ala  of  the  nose  (Wellenschnitt  of  Dieffen- 
bach). 


OPERATIONS  FOE  HARELIP,  CLEFT  PALATE,  ETC.  HI 

An  attempt  may  be  made  to  gradually  force  the  intermaxillary 
segment  into  place  by  long-continued  pressure.  If  this  method  is 
to  be  tried,  the  double  cleft  is  closed  after  having  first  liberated  the 
side  flaps  by  an  incision,  on  either  side,  around  the  wing  of  the  nose 
(Dieffenbach's  Wellensclmitt),  and  then  an  elastic  band  is  applied  which 
exerts  pressure,  continuously,  upon  the  middle  segment.  This  band- 
age must  we  worn  for  a  long  time. 

Immediate  forcible  replacement  of  the  intermaxillary  portion 
may  be  done.  It  is  seized  with  the  forceps  and  broken  away  from  the 
vomer,  or  the  line  of  fracture  may  extend  upward  and  backward 
through  the  vomer  proper.  The  segment  is  then  forced  back  into 
proper  position  and  the  edges  of  the  flaps  freshened  and  sutured. 

Blandin  recommends  the  resection  of  a  triangular-shaped  por- 
tion from  the  nasal  septum  posterior  to  the  intermaxillary  segment. 
The  base  of  the  triangular  piece  of  bone  which  is  thus  resected 
corresponds  in  width  to  the  space  that  intervenes  between  the  mid- 
dle segment  and  the  intermaxillary  notch,  its  apex  running  upward 
into  the  septum  of  the  nose.  In  young  children  this  resection  may 
be  made  with  a  pair  of  ordinary  strong  scissors,  but  in  children 
over  ten  years  of  age  it  will  be  necessary  to  use  the  bone  scissors. 
The  apex  of  the  resected  triangular  piece  should  be  directed  upward 
and  forward,  toward  the  bridge  of  the  nose,  in  order  to  avoid  the 
anterior  palatine  vessels.  The  intermaxillary  segment  may  then 
be  readily  forced  back  into  proper  position  and  the  cleft  closed.  If 
the  anterior  naso-palatine  artery  is  cut  in  removing  the  triangular 
piece  of  bone,  the  hemorrhage  will  be  severe. 

Bardeleben  has  modified  the  above  procedure  in  that  he  first 
separates  the  periosteum,  upon  either  side  of  the  septum,  behind  the 
middle  segment,  and  then,  with  the  ordinary  strong,  straight  scissors, 
simply  cuts  through  the  septum  without  attempting  to  resect  a  tri- 
angular piece.  The  middle  segment  is  then  pushed  back  into  place, 
the  edges  of  the  divided  septum  sliding  past  and  overlapping. 

As  a  rule,  the  attempt  to  replace  the  middle  segment  should 
be  made  during  the  first,  second,  or  third  year  of  the  patient's  life, 
because  later  the  segment  becomes  too  large  and  the  corresponding 
intermaxillary  space  too  small. 

Many  surgeons  make  it  a  rule  to  excise  the  intermaxillary  bone 
entirely,  and  indeed  it  is  very  questionable  if  anything  is  gained  by 
leaving  or  replacing  a  deformed,  misplaced  middle  portion.  If  it  is  re- 
moved, the  four  incisor  teeth  are  lost,  but  a  plate  can  be  fitted  to  sub- 


112  HEAD  AND  FACE. 

stitute  for  these.  If  the  intermaxillary  bone  is  allowed  to  remain  and 
is  replaced,  it  is  very  likely  to  remain  rudimentary  and  wabbly,  and  the 
corresponding  teeth  are  apt  to  be  crooked  and  imperfect.  If  a  con- 
siderable part  of  the  septum  of  the  nose  has  been  removed,  in  order  to 
place  the  intermaxillary  portion  in  its  normal  position,  the  point  of 
the  nose  will  be  drawn  down  so  close  to  the  front  of  the  face  as  to 
give  it  a  peculiar  flattened,  "bird-like"  appearance. 

Operation  for  Cleft  Palate. — The  cleft  may  be  limited  to  the 
soft  or  hard  palate  or  may  extend  through  both. 

The  operation  upon  the  soft  palate  is  called  staphylorrhaphy; 
that  upon  the  hard  palate,  uranoplasty.  At  times  cleft  palate  is 
combined  with  harelip.  This  latter  condition  may  be  remedied  dur- 
ing the  first  few  months  of  life,  leaving  the  cleft  in  the  palate  until 
later:  seventh  to  eighth  year.  Julius  Wolff  operates  upon  cleft 
palate  earlier,  during  the  second  or  third  year,  and  this  seems  ad- 
visable. The  operation  for  closure  of  a  complete  cleft  may  be  done 
in  two  sittings :  closure  of  the  hard  palate  first  and  the  soft  palate 
subsequently  at  a  second  sitting.  As  a  rule,  however,  it  is  preferable 
to  close  the  entire  cleft  at  one  sitting. 

The  operation  is  probably  best  done  with  the  head  in  the  Eose 
position,  the  patient  lying  upon  the  back,  with  the  head  hanging 
over  the  end  of  the  table,  and  under  complete  anaesthesia  (chloro- 
form). Some  operators  advise  a  preliminary  tracheotomy  with  the 
introduction  of  a  tampon  cannula;  or  an  ordinary  tracheotomy  tube 
may  be  introduced,  in  this  latter  case,  packing  the  pharynx,  in  addi- 
tion, with  a  pad  of  gauze.  Blood  is  thus  prevented  from  entering 
the  larynx,  and  the  anaesthetic  is  administered  through  the  trache- 
otomy tube.  Even  when  these  measures  are  resorted  to,  the  Eose 
position  is  still  preferable.  The  mouth,  teeth,  and  nasal  passages 
should  be  thoroughly  cleansed  and  disinfected,  and  during  the  op- 
eration the  mouth  and  nose  may  be  frequently  irrigated  with  a  hot, 
saline  solution,  which  cleanses  the  parts  and  checks  hemorrhage.  The 
corners  of  the  mouth  are  retracted  with  curved  retractors  held  by 
an  elastic  band  fastened  around  the  patient's  neck.  The  jaws  are 
held  apart  with  a  Smith  or  Whitehead  gag,  which  not  only  holds 
the  jaws  open,  but  at  the  same  time  depresses  the  tongue.  If  this 
gag  is  used,  the  retractors  for  the  side  of  the  mouth  may  be  dis- 
pensed with.  Bleeding  is  controlled  by  pressure  with  hot  pads  on 
long  sponge  holders,  and  one  should,  at  short  intervals,  interrupt 
the  operation  for  this  purpose;   usually  the  hemorrhage  is  simply  an 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC.  113 

oozing  from  the  cut  edges.  By  carefully  minimizing  the  loss  of  blood 
we  are  enabled,  with  safety,  to  operate  upon  quite  young  children: 
less  than  two  years  of  age  (Julius  Wolff). 

Staphylorrhaphy. — Closure  of  a  split  in  the  soft  palate.  The 
first  step  of  the  operation  consists  in  freshening  the  edges  of  the  cleft. 
The  free  extremity  of  one  side  of  the  split  uvula  is  seized  with  a  long 
mouse-tooth  forceps,  and,  while  the  uvula  is  thus  held  taut,  it  is 
transfixed,  near  its  tip,  which  is.  steadied  in  the  grasp  of  the  forceps, 
with  a  narrow-bladed,  sharp-pointed,  double-edged  knife,  and  with  a 
sawing  motion  a  thin  strip  is  cut  away  from  its  margin;  the  edge 
is  pared  along  the  entire  extent  of  the  split  toward  the  posterior 


Fig.  61.— Whitehead  Gag  and  Tongue  Depressor  in  Place.    For  operations 
upon  the  hard  and  soft  palate. 


border  of  the  hard  palate.  The  opposite  edge  is  then  freshened 
in  a  like  manner  and  the  strips  finally  cut  away  from  the  tip  of  the 
uvula.  Care  should  be  taken  to  freshen  the  angle  of  the  split.  The 
strips  should  be  so  cut  that  the  freshened  margins  present  a  beveled 
edge,  more  tissue  being  taken  away  from  the  buccal  than  from  the 
nasal  aspect  of  the  soft  palate,  so  as  to  give  us  broader  surfaces  for 
suture.  The  freshening  of  the  margin  of  the  split  may  be  done  with 
long,  narrow-bladed  scissors  instead  of  with  the  knife.  After  the 
edges  have  been  freshened,  one  should,  with  sharp  tenacula,  attempt 
to  appose  the  raw  edges  in  order  to  estimate  what  degree  of  tension, 
if  any,  exists.  It  is  absolutely  necessary  that  there  be  no  tension 
whatever.    In  order  to  overcome  tension  of  the  soft  palate  a  liberat- 


114  HEAD  AND  FACE. 

ing  incision  may  be  made  upon  either  side.  These  incisions  are  made 
with  a  narrow-bladed,  double-edged  knife,  which  is  introduced  just  to 
the  inner  side  of  the  hamular  process.  This  process,  which  is  located 
behind  and  internal  to  the  last  molar  tooth,  is  very  readily  felt. 
These  incisions  pass  through  the  entire  thickness  of  soft  palate,  from 
behind  forward,  and  divide  the  tendons  of  the  levator  and  tensor 
palati  as  they  turn  around  the  hamular  process  to  spread  out  into 
the  soft  palate.  One  may  wait  with  these  incisions  until  after  the 
soft  palate  has  been  sutured,  since  they  may  not  be  necessary,  espe- 
cially if  care  has  been  taken  to  thoroughly  detach  the  soft  palate 
from  the  posterior  border  of  the  hard  palate  and  also  from  the 
adjoining  portion  of  the  pterygoid  process,  which  corresponds  to  the 
most  external  portion  of  the  posterior  border  of  the  hard  palate. 
If  this  separation  is  thorough,  the  two  halves  of  the  soft  palate  may 
be  readily  approximated  without  tension  and  the  liberating  incisions 
can  be  dispensed  with  (Julius  Wolff).  Even  when  the  cleft  is  limited 
to  the  soft  palate,  it  may  be  advantageous  to  raise  a  muco-periosteal 
flap,  the  same  as  when  closing  clefts  of  the  hard  palate;  so  that, 
working  underneath  this  flap,  close  to  the  surface  of  the  bone,  the 
soft  palate  may  be  completely  separated  from  the  posterior  border 
of  the  hard  palate.  This  step  of  the  operation  is  accomplished  with 
a  periosteum  elevator  bent  near  the  end  to  almost  a  right  angle. 

To  unite  the  freshened  edges  of  the  soft  palate  a  small,  short, 
surgeon's  needle  with  a  moderate  curve  or  a  short,  straight  needle 
may  be  used.  The  needle  is  carried  in  a  long  needle  holder,  and  as 
it  pierces  the  tissues  its  end  may  be  seized  with  an  artery  forceps 
for  the  purpose  of  withdrawing  it.  A  combination  needle  and  holder 
in  one  piece  is  preferred  by  some  surgeons. 

The  stitches,  which  may  be  of  silk,  silk-worm  gut,  or  silver  wire, 
are  introduced  from  before  backward,  and  are  not  tied  until  they 
are  all  placed.  Instead  of  tying  the  sutures  they  may  be  fixed  with 
perforated  shot.  To  prevent  the  suture  ends  becoming  confused 
one  may  confine  them  temporarily,  until  ready  to  tie  them,  in  in- 
cisions cut  in  a  piece  of  cardboard.  From  four  to  five  sutures  are 
required,  and  they  should  be  placed  about  one-fourth  inch  apart. 
The  edges  of  the  soft  palate  should  be  accurately  apposed  without 
tension  and  free  from  hemorrhage. 

Uranoplasty. — Closure  of  clefts  of  the  hard  palate.  The  op- 
eration of  Langenbeck  as  described  by  him  in  1862.  This  condition 
is  usually  associated  with  cleft  of  the  soft  palate,  in  which  case  both 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC.      115 

should  be  closed  at  the  same  time.  The  tip  of  one  side  of  the  uvula 
is  seized  with  a  long,  mouse-tooth  forceps  and  transfixed  as  described 
above.  The  paring  process  is  carried  forward  as  far  as  the  poste- 
rior border  of  the  hard  palate  and  then  continued  along  the  margin 
of  the  cleft  in  the  hard  palate,  close  to  its  edge,  cutting  through  the 
muco-periosteal  covering  down  to  the  surface  of  the  bone,  as  far  as 
the  anterior  limit  of  the  cleft.  Upon  the  other  side,  beginning, 
again,  behind,  near  the  tip  of  the  soft  palate,  the  margin  of  the 
cleft  in  the  soft  palate  and  in  the  hard  palate  is  freshened  in  a 
similar  manner.  During  this  step  of  the  operation  one  should  pause 
occasionally  for  a  few  minutes  and  apply  steady,  firm  pressure  with 
a  hot  pad  in  order  to  control  the  bleeding. 

The  next  step  of  the  operation  is  the  raising  of  a  muco-periosteal 
flap  from  the  surface  of  the  hard  palate  upon  either  side  of  the 
cleft.  An  incision,  corresponding  to  the  length  of  the  cleft,  is  made 
upon  the  surface  of  the  hard  palate  and  close  along  the  inner  margin 
of  the  alveolar  process.  This  incision  usually  extends  from  a  point 
anteriorly,  behind  the  incisor  teeth,  to  a  point  posteriorly,  beyond 
the  last  molar  tooth.  In  making  this  incision  we  should  remember 
the  point  where  the  posterior  palatine  artery  emerges  from  the  canal 
in  the  back  part  of  the  palate,  and  place  the  incision  fairly  close  to 
the  alveolar  process  so  that  this  vessel  may  be  left  in  the  flap  to 
nourish  it  and  also  in  order  that  we  may  avoid  the  hemorrhage  that 
would  follow  its  division.  Many  surgeons  claim  that  it  is  a  matter  of 
indifference  whether  this  vessel  is  cut  or  not,  as  the  flap  is  nourished 
just  the  same  in  either  case  and  that  the  resulting  hemorrhage  is  read- 
ily controlled  by  pressure;  nevertheless  one  should  try  to  avoid  divid- 
ing it.  Into  this  incision  a  sharp  periosteum  elevator  is  introduced, — 
it  may  be  narrow  and  rather  bent  near  the  end, — and  with  this  the 
muco-periosteal  layer  is  lifted  away  from  the  surface  of  the  bone  and 
thus  made  freely  movable  so  that  it  can  be  brought  over  to  meet  the 
edges  of  the  flap  on  the  opposite  side.  Care  should  be  exercised  to 
separate  thoroughly  the  soft  palate  from  the  whole  posterior  border  of 
the  hard  palate.  This  is  accomplished  by  working  close  to  the  surface 
of  the  bone  with  a  periosteum  elevator  bent  upon  itself.  If  this 
detachment  of  the  soft  palate  is  thorough,  it  will,  in  nearly  all  in- 
stances, do  away  with  the  necessity  for  liberating  incisions,  etc. 

The  apposed  edges  of  the  cleft  are  now  sutured  together,  com- 
mencing in  front,  behind  the  incisor  teeth,  and  working  backward, 
completing  the  operation  by  uniting  the  edges  of  the  soft  palate.    As 


116 


HEAD  AND  FACE. 


already  mentioned,  the  sutures  are  not  tied  until  after  they  have 
all  been  placed.  The  raw  space  left  on  either  side  of  the  hard 
palate  after  raising  the  muco-periosteal  flaps  is  packed. 

Ordinarily  the  sutures  may  be  removed  after  six  days.  The 
mouth  and  nose  should  be  irrigated  and  washed  out  frequently  both 
during  and  subsequent  to  the  operation.  If  a  preliminary  trache- 
otomy has  been  performed  the  mouth  may  be  packed,  the  patient 
breathing  freely  through  the  tracheotomy  tube.  The  original  defect 
of  the  hard  palate  is  closed  ultimately  by  the  bone  which  is  produced 
from  the  periosteal  surface  of  the  flaps. 


Fig.  62. — Repair  of  Cleft  Palate.  Muco-periosteal  flaps  raised  and  edges 
of  cleft  in  hard  and  soft  palate  pared.  Sutures  all  introduced  and  ready  for 
tying. 

OPERATIONS  UPON  THE  LIPS. 

Excision  of  the  Whole  Lower  Lip. — This  operation  is  done  for 
malignant  disease.  At  times  the  angle  of  the  mouth  is  involved 
and  the  upper  lip  is  also  encroached  upon,  so  that  it  becomes  neces- 
sary, in  addition  to  excising  the  lower  lip,  to  excise  a  triangular 
portion  of  the  upper  lip.  The  cutting  is  done  with  a  scissors,  and 
during  the  operation  the  bleeding  is  controlled  by  compression  with 
the  fingers.  If  the  jaw-bone  is  involved  in  the  disease  one  may  resect 
the  diseased  portion  with  the  chisel  or  saw,  but  should  leave,  if  pos- 
sible, a  bridge  of  bone  sufficient  to  preserve  the  continuity  of  the 
jaw. 


OPERATIONS  UPON  THE  LIPS. 


117 


Restoration  of  the  Lower  Lip  After  Excision  of  a  Wedge-shaped 
Portion. — After  the  whole  lower  lip  has  been  removed,  the  triangular- 
shaped  defect  that  remains  may,  in  many  cases,  be  remedied  by  sim- 
ply drawing  the  edges  of  the  wound  together.  The  edges  of  the 
wound  may  be  united  with  several  sutures  of  rather  heavier  silk 
which  go  through  the  entire  thickness  of  the  lip  down  to,  but  not 
including,  the  mucous  membrane,  and  these  may  be  placed  so  as 
to  control  the  hemorrhage  at  the  same  time.  There  are  then  applied 
additional  sutures  of  finer  silk  that  bring  the  edges  of  the  wound 
accurately  together.  As  a  result,  we  have  a  small,  rounded,  puck- 
ered opening,  representing  the  mouth,  which  is  formed  entirely  from 


Fig.  63.— Excision  of  Entire  Lower 
Lip,  with  Resulting  Triangular  De- 
fect. 


Fig.   64. — Triangular   Defect  in   Lower 
Lip  Closed  by  Suture. 


the  upper  lip,  but  this  regains  an  appearance  very  much  like  normal, 
after  six  to  eight  months. 

Formation  of  the  Lower  Lip  After  Complete  Excision.  Dieffen- 
bach-Jaesohe  Method. — To  remedy  a  triangular  defect  in  the  lower 
lip.  In  estimating  the  area  of  the  flaps  required  one  should  allow 
one-third  for  shrinkage. 

From  each  corner  of  the  mouth  an  incision  is  carried  outward 
and  somewhat  upward  into  the  cheek  for  a  sufficient  distance  to 
close  the  defect  in  the  lip,  allowing  one-third  for  shrinkage.  From 
the  end  of  each  of  these  incisions  a  second  curved  incision  is  then 
carried  downward  and  inward  toward  the  chin  so  as  to  terminate 
near  the  lower  border  of  the  jaw  and  under  the  angle  of  the  mouth. 


118  HEAD  AND  FACE. 

Stenson's  duct  should  be  avoided  in  making  these  flaps.  This  second 
incision,  being  curved,  makes  the  flaps  more  movable.  The  mucous 
membrane,  corresponding  to  that  part  of  the  incision  that  reaches 
outward  from  the  corner  of  the  mouth,  should  be  cut  upon  a  higher 
level  than  the  skin  in  order  thus  to  obtain  a  mucous  membrane  flap 
which  may  be  sutured  to  the  edge  of  the  skin  to  form  the  free  border 
of  the  new  lower  lip.  For  the  rest  of  its  extent  the  incision  goes 
through  the  skin  and  mucous  membrane  upon  the  same  level.  The 
two  flaps  are  now  separated  from  the  lower  jaw,  avoiding,  as  far  as 
possible,  cutting  the  fold  of  mucous  membrane  that  is  reflected  from 
the  inner  surface  of  the  lips  to  the  gums.  If  the  flaps  are  not  suffi- 
ciently movable  to  bring  them  together,  -the  incisions  may  be  pro- 


Fig.  65.— Dieffenbach-Jaesche  Operation  for  Restoring  Lower  Lip.  Dotted 
lines  represent  the  edges  of  the  mucous  membrane,  which  is  cut  long  in  order 
to  cover  over  the  free  margin  of  the  new  lip.  The  edges  of  the  flaps  are 
drawn  together  and  the  mucous  membrane,  which  was  cut  long,  is  sewed 
over  the  free  edge  of  the  new  lip.  The  defect  vpon  each  side  caused  by  the 
sliding  of  the  flaps  is  closed  by  suture. 

longed  downward  beyond  the  lower  border  of  the  jaw  into  the  neck 
and  the  flaps  loosened  still  farther  from  the  lower  jaw.  The  edges 
of  the  flaps  are  then  united  with  interrupted  silk  sutures  which  in- 
clude the  whole  thickness  of  the  lip  down  to,  but  not  including,  the 
mucous  membrane.  A  second  set  of  intermediate  silk  sutures  brings 
the  edges  of  the  skin  and  mucous  membrane  into  accurate  apposi- 
tion. Corresponding  to  the  free  border  of  the  new  lip,  the  edges 
of  the  mucous  membrane  flaps,  which  were  intentionally  cut  long, 
are  sutured  to  the  skin.  Finally  the  semilunar  defects  upon  either 
side  are  closed  with  sutures.  In  the  male  the  scar  is  hidden  by  the 
beard. 

Bruns  Method. — For  a  quadrangular  defect  of  the  lower  lip. 
A  square  cornered  flap  is  taken  from  either  side  of  the  face,  includ- 


OPERATIONS  UPON  THE  LIPS. 


119 


ing  the  whole  thickness  of  the  cheek,  and  these  are  turned  down 
into  the  defect  through  an  angle  of  ninety  degrees.  These  flaps 
have   a   good,  blood-supply.     Avoid    Stenson's    duct.      The   apposed 


Fig.  66.— Bruns  Method  of  Restoring 
the  Lower  Lip.  Dotted  lines  indicate 
that  the  mucous  membrane  is  cut 
longer  than  the  skin  in  order  to  pro- 
vide a  mucous  membrane  border  to  the 
new  lip. 


Fig.  67. — Flaps  Turned  down  and 
Joined  to  Form  New  Lip.  Mucous 
membrane  is  sutured  over  the  free 
margin  of  the  new  lip.  The  defect 
upon  each  side  of  the  cheek  is  closed 
by  suture. 


edges  of  the  flaps  are  united  and  the  mucous  membrane  sutured  to 
the  edge  of  the  skin  to  form  the  free  margin  of  the  new  lip.  The 
lateral  defect  on  either  side  is  then  closed.  The  scars  that  result  are 
upon  the  cheek. 


Fig.    68. — Langenbeck    Method    of    Re-  Fig.  69.— Oval  Flap  is  Raised  and  Su- 

Btoring  the  Lower  Lip.     An  oval  flap  is      tured    into    Place    and    the    Defect   thus 
taken  from  the  region  of  the  chin.  Closed. 

Langenbeck's  Method. — Formation  of  the  lower  lip  for  oval 
defect.  A  long,  rounded  flap  is  taken  from  the  region  of  the  chin 
with  its  base  directed  upward   and  outward.     Between  the  upper 


120 


HEAD  AND  FACE. 


border  of  the  flap  which  is  thus  marked  out  and  the  lower  margin 
of  the  defect  there  is  a  triangular  tongue  of  tissue.  This  tongue  of 
tissue  is  partly  loosened  from  its  attachment  to  the  underlying  tis- 
sues. The  long  flap  is  raised  from  the  underlying  parts  and  shoved 
upward,  filling  in  the  defect  in  the  lip,  and  the  triangular  tongue 
of  tissue  is  brought  under  it.  These  flaps  are  fixed  in  their  new 
position  with  sutures.  The  whole  defect  may  be  closed  over  if  the 
flaps  are  sufficiently  detached.  The  great  disadvantage  of  this 
method  is  that  the  new  lip,  upon  its  free  edge  and  posterior  surface, 
is  not  covered  by  mucous  membrane,  and  shrinks  and  contracts  as 
it  cicatrizes. 


Fig.  70.—  Estlaender's  Method  of  Re- 
Storing  the  Lower  Lip  After  Partial 
Excision.  A  triangular  flap  is  taken 
from  the  upper  lip  and  cheek. 


Fig.  71.  —  The  Triangular  Flap  is 
Turned  down  and  Sutured  in  Place, 
thus  Closing  the  Defect. 


Estlaender's  Method. — As  large  a  defect  as  that  left  after 
excision  of  three-fourths  of  the  lower  lip  may  be  covered  by  this 
method.  An  incision  is  made  reaching  from  the  corner  of  the  mouth 
upward,  through  the  whole  thickness  of  the  cheek,  to  the  level  of  the 
infra-orbital  foramen  and  then  downward,  past  the  wing  of  the  nose, 
toward  the  philtrum,  to  a  point  close  to  the  carmine  border  of  the 
upper  lip.  If  the  coronary  branch  of  the  facial  artery  is  not  divided, 
the  flap  will  be  well  nourished.  The  flap  is  then  turned  down  into 
the  defect  in  the  lower  lip  through  an  angle  of  one  hundred  and 
seventy  degrees.  One  may  feel  the  pulsating  coronary  artery  before 
cutting  the  flap  and  should  positively  avoid  severing  it. 

The  resulting  deformity  is  bad,  the  mouth  one-sided,  the  corner 
of  the  mouth  corresponding  to  the  philtrum.  In  order  to  correct 
this  feature  a  subsequent  operation  might  be  done,  extending  the 


OPERATIONS  UPON  THE  LIPS. 


121 


corner  of  the  mouth  outward,  but  it  would  be  necessary  to  wait  at  least 
six,  weeks,  in  order  to  insure  a  good  blood-supply,  before  undertaking 
this  second  operation,  otherwise  there  would  be  danger  of  gangrene. 
Without  doubt  this  deformity  will,  in  time,  correct  itself  to  a  consider- 
able degree,  so  that  the  secondary  operation  may  not  be  necessary. 


WO 


Fig.  72.— D'effenbach  Wellenschnitt  for 
Restoration  of  the  Upper  Lip.  An  in- 
cision (WD)  is  carried  around  each  side 
of  the  nose,  extending  through  the 
cheek. 


F'g.  73.— The  Flaps  are  Liberated 
from  the  Upper  Jaw-bone  and  are 
Drawn  Down  into  Place  and  Sutured. 
The  raw  space  upon  either  side  of  the 
nose  is  closed  with  suture. 


Restoration  of  the  Upper  Lip. — Eestoration  of  the  upper  lip  is 
not  often  required,  as  this  part  is  but  rarely  the  seat  of  disease  that 
calls  for  its  excision. 


Fig.  74.— Bruns  Method  of  Restoring 
Upper  Lip.  A  square  flap  taken  from 
either  cheek. 


Fig.  75. — Flaps  are  Turned  down  into 
Place  and  Sutured.  Defect  in  either 
cheek  is  closed  with  sutures. 


Estlaender's  Method  may  be  used  to  close  a  wedge-shaped 
defect  in  the  upper  lip,  the  flap  being  taken  from  the  lower  lip. 

Dieffenbach's  Wellenschnitt. — A  curved  incision  is  made 
through  the  whole  thickness  of  the  cheek  around  the  corner  of  the 


122  HEAD  AND  FACE. 

nose.  The  flaps  which  are  thus  marked  out  are  separated  from  the 
maxillae  and  then  drawn  toward  the  middle  line  and  turned  down, 
so  that  the  raw  edges  of  the  original  defect  become  the  free  border 
of  the  new  lip.  The  two  flaps  are  then  united  and  the  edges  of  the 
mucous  membrane  and  skin  sutured  together  along  the  free  margin 
of  the  new  lip.  The  mucous  membrane  corresponding  to  this  margin 
may  be  cut  a  little  longer  than  the  skin,  in  order  to  facilitate  the 
union  of  these  edges.  After  uniting  the  flaps  in  the  middle  line  the 
edges  of  the  defect  around  the  side  of  the  nose  may  be  brought 
together  with  sutures. 

Small,  wedge-shaped  defects  may  be  closed  by  simple  suture, 
if  necessary,  combining  this  with  detachment  of  the  cheek  by  Dief- 
fenbach's  Wellenschnitt. 

Beuns  Method  may  also  be  used  to  restore  the  upper  lip  after 
its  complete  excision. 


PART  III. 

NECK   AND  TONGUE. 


SURGICAL  ANATOMY  OF  THE  NECK. 

The  neck  is  the  constricted  part  of  the  body  that  joins  the  head 
to  the  trunk.  The  spinal  column  passes  through  the  posterior  part 
of  the  neck,  inclosing  within  its  canal  the  spinal  cord.  The  anterior 
part  of  the  neck  is  made  up  of  important  organs  and  of  channels 
that  pass  between  the  head  and  the  trunk. 

The  Deep  Cervical  Fascia. — This  is  an  aponeurotic  layer  that 
serves  to  bind  the  structures  that  comprise  the  neck,  into  a  com- 
pact, cylindrical  mass.  This  fascia  offers  a  strong  barrier  to  the 
extension  of  superficial  suppurative  processes  into  the  deeper  parts 
of  the  neck,  and  at  the  same  time  hinders,  to  a  considerable  degree, 
the  spontaneous  evacuation,  externally,  of  pus  which  is  located  deep 
in  the  neck. 

Anteriorly,  between  the  edges  of  the  sterno-mastoid  muscle,  the 
deep  cervical  fascia  covers  the  depressor  muscles  of  the  hyoid  bone — 
the  sterno-hyoid,  sterno-thyroid,  and  omo-hyoid.  Upon  the  side  of 
the  neck  it  is  found  beneath  the  sterno-mastoid,  and  may  be  traced 
from  the  posterior  border  of  this  muscle  backward  across  the  poste- 
rior triangle  of  the  neck  and  beneath  the  trapezius  muscle,  where 
it  serves  to  bind  the  long  muscles  of  the  neck  to  the  vertebral 
column. 

Above,  the  deep  cervical  fascia  is  attached  to  the  lower  border 
of  the  jaw  and  to  the  back  of  the  skull,  and,  below,  to  the  upper 
border  of  the  sternum,  the  clavicle,  the  spine  of  the  scapula,  and 
the  spinous  process  of  the  seventh  cervical  vertebra:  vertebra  prom- 
inens.  In  the  middle  line  of  the  neck,  behind,  the  deep  cervical 
fascia  is  blended  with  the  ligamentum  nucha?,  which  is  prolonged 
deep  into  the  neck  to  be  attached  to  the  tips  of  the  spinous  processes 
of  the  cervical  vertebras.  The  deep  cervical  fascia  is  firmly  attached 
to  the  body  and  horns  of  the  hyoid  bone. 

Anteriorly,  between  the  edges  of  the  sterno-mastoid  muscles, 
the  deep  cervical  fascia  covers  the  depressor  muscles  of  the  hyoid 
bone,  and  consists  of  two  layers,  the  anterior  of  which  is  attached 

(123) 


124  NECK  AND  TONGUE. 

to  the  anterior  and  the  posterior  to  the  posterior  margin  of  the 
upper  border  of  the  sternum.  Between  the  two  layers  there  is  a 
space  known  as  the  suprasternal  space,  which  contains  some  fat, 
lymphatic  tissue,  and  a  venous  branch,  the  anterior  jugular,  that 
enters  the  external  jugular  beneath  the  attachment  of  the  sterno- 
mastoid. 

The  suprasternal  space  extends  upward  almost  as  far  as  the 
hyoid  bone  and  laterally  as  far  as  the  anterior  edge  of  the  sterno- 
mastoid  muscle. 

A  suppurative  process  in  this  space  is  pretty  effectively  shut  off 
from  the  deep  parts  of  the  neck  by  the  posterior  layer  of  the  deep 
cervical  fascia. 

In  the  front  part  of  the  neck,  below  the  level  of  the  hyoid  bone, 
the  pharynx  and  oesophagus  and  the  larynx  and  trachea  are  bound 
together  in  a  single  bundle  by  a  layer  of  fascia  that  completely  en- 
velops them;  the  thyroid  gland  is  also  included  within  this  sheath 
of  fascia  and  is  fixed  by  it  to  the  trachea.  Another  layer  of  fascia 
forms  a  sheath  for  the  muscles  that  are  contiguous  to  the  vertebral 
column:  anteriorly,  the  recti  and  longus  colli;  laterally,  the  scaleni, 
cords  of  the  brachial  plexus,  and  the  levator  anguli  scapulae;  poste- 
riorly, the  splenius,  complexus,  etc. 

Above  the  hyoid  bone  the  deep  cervical  fascia  reaches  from  the 
body  of  the  jaw-bone  to  the  hyoid  bone.  The  submaxillary  gland, 
surrounded  by  a  mass  of  loose  connective  tissue,  is  lodged  in  the 
submaxillary  triangle,  beneath  the  deep  cervical  fascia. 

Connective-Tissue  Spaces  Beneath  the  Deep  Cervical 
Fascia.  Prcevisceral  Space. — This  space  corresponds  to  a  mass  of 
loose  connective  tissue  that  is  situated  in  front  of  the  trachea  and 
thyroid  gland  and  beneath  the  deep  cervical  fascia  and  depressor 
muscles  of  the  hyoid  bone. 

If  an  opening  is  made  in  the  deep  fascia  and  a  probe  introduced 
into  this  space,  it  may  be  readily  forced  down  into  the  mediastinum, 
and  a  collection  of  pus  in  this  space  may  readily  gravitate  along  the 
same  route  into  the  mediastinum  with  fatal  results. 

Retrovisceral  Space. — This  is  the  recess  between  the  pharynx 
and  oesophagus  in  front  and  the  vertebral  column  behind;  it  reaches 
from  the  base  of  the  skull  down  into  the  chest.  Pus  in  this  space 
may  readily  find  its  way  down  along  this  path  into  the  chest. 

Vascular  Space. — Upon  either  side  of  the  pharynx  and  oesoph- 
agus and  the  larynx  and  trachea  the  carotid  artery  and  its  adjoining 


VAM 


Fig.  76.— Section  through  the  Neck,  Level  of  Sixth  Cervical  Vertebra,  to 
Show  Arrangement  of  the  Deep  Cervical  Fascia  (Indicated  in  Red).  BP, 
trunks  of  brachial  plexus;  C,  complexus  muscle;  EJ,  external  jugular  vein; 
E8,  oesophagus;  LA,  levator  anguli  scapulas  muscle;  OH,  omo-hyoid  muscle; 
P,  platysma  muscle;  PV,  prssvisceral  space:  1'V,  retrovisceral  space;  8,  S1, 
splenius  capitis  et  colli  muscle;  8  A,  scalenus  anticus  muscle;  SC,  semi- 
spinalis  colli  muscle;  SH,  sterno-hyoid  muscle;  SM,  scalenus  medius  muscle; 
88,  suprasternal  space;  8T,  sterno-thyroid  muscle;  ST.M.,  sterno-mastoid 
muscle;  8Y,  sympathetic  nerve;  TP,  trapezius  muscle;  TR,  trachea;  TY, 
thyroid  gland;  V,  vertebral  artery  and  vein;  VAN,  internal  jugular  vein, 
carotid  artery,  and  pneumogastric  nerve  inclosed  in  a  mass  of  loose  connec- 
tive tissue. 


SURGICAL  ANATOMY  OF  THE  NECK.  125 

structures  are  found.  These  structures,  beside  the  carotid  artery, 
consist  of  the  internal  jugular  vein  and  pneumogastric  nerve,  sym- 
pathetic nerve,  and  loop  formed  by  the  descendens  and  communicans 
noni.  These  structures  are  not  provided  with  a  distinct  sheath,  but 
are  lodged  in  a  mass  of  loose  connective  tissue,  which  may  be  traced 
all  the  way  down  into  the  thoracic  cavity. 

Suppuration  may  spread  along  the  course  of  these  structures, — 
for  example,  the  internal  jugular  vein, — and  thus  invade  the  chest 
cavity. 

The  Back  of  the  Neck. — This  region  of  the  neck  corresponds  to 
the  cervical  portion  of  the  trapezius  muscle.  It  is  limited  above  by 
the  occipital  protuberance  and  superior  curved  line  of  the  occipital 
bone,  below  by  the  vertebra  prominens,  and  upon  the  sides  by  the 
edges  of  the  trapezius  muscle. 

The  skin  of  this  region  is  intimately  united  with  the  subcuta- 
neous connective  tissue,  which  is  very  dense  and  is  marked  by  hair- 
follicles  and  sebaceous  glands.  Inflammatory  processes  which  attack 
the  structures  of  the  skin  in  this  region  show  but  little  tendency 
to  spread  and  are  excessively  painful  (carbuncles). 

This  region  presents  two  longitudinal,  rounded  swellings — one 
on  either  side  of  the  middle  line — which  correspond  to  the  trapezius 
muscle.  Between  these,  in  the  middle  line,  is  a  depression  marked 
by  the  spinous  processes  of  the  cervical  vertebra?.  The  spinous 
processes  of  the  cervical  vertebrae  are  short  and  not  distinctly  felt, 
except  the  lower  ones;  that  of  the  seventh,  the  vertebra  prominens, 
is  especially  prominent.  They  are  joined  together  by  a  dense,  liga- 
mentous band, — the  ligamentum  nucha?, — which  is  continued  upward 
as  far  as  the  external  occipital  protuberance.  The  cervical  portion 
of  the  vertebral  canal  is  roomy  and  contains  the  spinal  cord.  This 
part  of  the  vertebral  column  lies  at  a  considerable  depth  from  the 
surface,  and  is  well  protected  by  the  overlying  muscles. 

The  Side  of  the  Neck. — This  region  is  quadrilateral;  bounded 
above  by  the  lower  border  of  the  jaw-bone  and  an  imaginary  line 
drawn  from  the  angle  of  the  jaw  to  the  mastoid  process;  below,  by 
the  clavicle;  in  front,  by  the  middle  line  of  the  neck;  and,  behind, 
by  the  anterior  border  of  the  trapezius.  It  is  divided  into  two  tri- 
angles— an  anterior  and  a  posterior — by  the  sterno-mastoid  muscle. 

The  sterno-mastoid  muscle  is  a  most  important  surgical  land- 
mark. It  is  attached  above  to  the  mastoid  process  and  the  adjacent 
part  of  the  occipital  bone;   below,  to  the  inner  end  of  the  clavicle 


126  NECK  AND  TONGUE. 

and  the  upper  end  of  the  sternum.  This  muscle  not  only  divides 
the  side  of  the  neck  into  an  anterior  and  a  posterior  triangle,  but, 
being  a  broad  muscle  itself,  covers  important  structures  not  seen  in 
either  of  the  triangles;  therefore  in  addition  to  the  triangles  one 
might  well  describe  a  sterno-mastoid  region. 

The  side  of  the  neck  is  covered  by  the  skin,  beneath  which  the 
subcutaneous  fat  and  superficial  fascia  are  found,  and,  beneath  these, 
there  is  a  broad,  thin,  muscular  layer:  the  platysma.  This  muscle, 
which  is  spread  out  in  a  thin  sheet,  extends  from  the  lower  border 
of  the  inferior  maxilla  downward  and  backward,  being  continued 
downward  beyond  the  clavicle,  where  it  is  blended  with  the  subcu- 
taneous tissue  of  the  upper  part  of  the  chest.  The  platysma  is  inti- 
mately united  with  the  skin,  and  together  with  it  is  freely  movable 
upon  the  parts  which  lie  beneath  it  and  with  which  it  and  the  skin 
are  united  by  loose  connective  tissue.  It  will  be  observed  that  the 
platysma  does  not  cover  the  anterior  portion  of  the  neck  in  the 
laryngeal  and  tracheal  regions. 

Beneath  the  superficial  fascia  and  the  platysma — i.e.,  between 
these  and  the  deep  cervical  fascia — are  found  the  external  and  ante- 
rior jugular  veins  together  with  some  nervous  branches  which  are 
derived  from  the  cervical  plexus  and  from  the  facial. 

The  External  Jugular  Vein,  during  efforts  of  straining  and 
in  conditions  of  obstructed  venous  return,  may  become  distended 
and  sufficiently  prominent  to  be  recognized  beneath  the  skin.  This 
vessel  is  formed  above,  behind  the  angle  of  the  jaw,  by  the  junction 
of  the  posterior  auricular  vein  and  the  posterior  branch  of  the  tem- 
poro-maxillary  vein;  it  passes  straight  down  the  side  of  the  neck, 
crossing  the  sterno-mastoid  muscle  from  its  anterior  to  its  posterior 
border,  and,  below,  pierces  the  deep  cervical  fascia,  just  above  the 
clavicle  and  behind  the  attachment  of  the  sterno-mastoid  to  this 
bone,  to  empty  into  the  subclavian.  After  it  pierces  the  deep  cervical 
fascia  and  before  it  terminates  in  the  subclavian,  which  it  does  just 
external  to  the  tendon  of  the  scalenus  anticus,  it  receives  the  supra- 
scapular, transverse  cervical,  and  anterior  jugular  veins. 

The  Anterior  Jugular  Vein. — This  is  formed  in  the  hyoid 
region  by  the  junction  of  several  veins  from  the  upper  anterior  part 
of  the  neck,  and  passes  downward,  anterior  to  the  edge  of  the  sterno- 
mastoid  muscle,  between  the  superficial  fascia  and  platysma  and  the 
deep  cervical  fascia;  in  the  lower  part  of  the  neck  it  pierces  the 
anterior  layer  of  the  deep  cervical  fascia  in  front  of  the  sterno- 


SURGICAL  ANATOMY  OF  THE  NECK.  127 

mastoid  and  then  passes  backward,  beneath  this  muscle,  through 
the  suprasternal  space,  to  join  the  external  jugular  just  before  this 
vessel  enters  the  subclavian.  The  external  and  anterior  jugular 
veins  are  often  cut  in  making  incisions  in  the  neck,  but  may  be 
readily  clamped  and  ligated  or  they  may  be  recognized  and  ligated 
before  they  are  cut. 

The  Nerves  that  are  found  in  this  part  of  the  neck  beneath 
the  superficial  fascia  and  platysma  are  some  superficial  ascending 
and  descending  branches  of  the  cervical  plexus  and  descending 
branches  from  the  facial;  these,  however,  are  of  no  special  surgical 
importance. 

The  Anterior  Triangle. — The  base  of  this  triangle  is  above, 
and  corresponds  to  the  lower  border  of  the  jaw  and  an  imaginary  line 
drawn  from  its  angle  to  the  mastoid  process.  Its  apex  is  below  at 
the  sterno-clavicular  articulation;  its  posterior  border  is  formed  by 
the  anterior  edge  of  the  sterno-mastoid  muscle,  and  its  anterior 
boundary  is  indicated  by  the  middle  line  of  the  neck. 

The  anterior  triangle  is  subdivided  into  an  upper  and  a  lower 
triangle  by  the  anterior  belly  of  the  omo-hyoid;  this  is  a  thin,  double- 
bellied  muscle  that  swings  obliquely  across  the  side  of  the  neck, 
being  attached  above  to  the  hyoid  bone  and  below  and  behind  to  the 
upper  border  of  the  scapula.  The  lower  triangle  is  called  the  in- 
ferior carotid,  and  the  upper,  the  superior  carotid  triangle.  The 
anterior  triangle  presents,  in  its  upper  part,  a  third  triangular  space: 
the  submaxillary  triangle. 

The  Posterior  Triangle. — This  is  the  reverse  of  the  anterior 
triangle.  Its  apex  is  above  at  the  mastoid  process;  its  base,  below, 
is  formed  by  the  clavicle;  its  anterior  border  corresponds  to  the 
posterior  edge  of  the  sterno-mastoid  muscle  and  its  posterior  border 
to  the  anterior  edge  of  the  trapezius.  The  posterior  triangle  is  sub- 
divided by  the  posterior  belly  of  the  omo-hyoid  into  two:  an  upper 
or  occipital  triangle,  and  a  lower  or  subclavian  triangle.  In  order 
to  demonstrate  these  triangles  it  is  necessary  to  draw  the  posterior 
belly  of  the  omo-hyoid  a  little  upward,  as  it  usually  lies  pretty  near 
the  clavicle,  being  fixed  in  this  position,  to  the  first  rib,  by  a  slip 
of  the  deep  cervical  fascia. 

Since  the  sterno-mastoid,  as  already  mentioned,  is  not  a  line, 
but  a  muscle  of  considerable  breadth  and  covers  structures  of  im- 
portance, one  might  describe,  besides  these  triangular  spaces  lying 
in  front  of  and  behind  the  sterno-mastoid  muscle,  a  "sterno-mastoid" 


123  NECK  AND  TONGUE. 

region,  and  we  will  proceed  to  do  this  at  once  and  thus  dispose  of 
it,  and  then  consider  the  triangles  more  in  detail. 

The  Sterno-mastoid  Kegion. — The  sterno-mastoid  region  is 
covered  by  the  skin  and  fat  (superficial  fascia)  and  to  a  considerable 
extent  by  the  platysma.  After  removing  these  layers  we  come  down 
upon  the  surface  of  the  muscle  covered  by  the  deep  portion  of  the 
superficial  cervical  fascia.  The  fibers  of  the  muscle  have  an  oblique 
direction  from  above  downward  and  forward,  and  it  is  crossed  from 
above  downward  by  the  external  jugular  vein. 

To  examine  the  structures  that  lie  beneath  the  sterno-mastoid, 
we  may  divide  the  muscle  through  its  middle  and  reflect  either  end. 
Then,  after  cutting  through  the  deep  cervical  fascia,  there  are  ex- 
posed the  deep  muscles  which  lie  beneath  the  sterno-mastoid  and 
which  are  connected  with  the  vertebral  column,  the  longus  colli, 
scaleni,  levator  anguli  scapulas,  etc.,  the  cervical  plexus  of  nerves, 
the  carotid  vessels,  internal  jugular  vein,  etc.,  and  numerous  lym- 
phatic glands. 

The  Inferior  Carotid  Triangle. — This  triangle  is  bounded 
in  front  by  the  middle  line  of  the  neck,  above  and  behind  by  the 
anterior  belly  of  the  omo-hyoid,  below  and  behind  by  the  anterior 
border  of  the  sterno-mastoid. 

This  triangle  contains  the  larynx,  trachea,  thyroid  gland,  and 
oesophagus.  These  structures  are  partly  covered  over  and  concealed 
by  the  sterno-hyoid,  sterno-thyroid,  and  thyro-hyoid1  muscles. 

The  oesophagus,  which  projects  well  beyond  the  left  border  of 
the  trachea,  is  more  accessible  in  the  left  triangle  than  in  the  right. 
Ascending  in  the  recess  between  the  trachea  and  the  oesophagus  is 
the  recurrent  laryngeal  nerve;  this  nerve  enters  the  larynx  between 
the  thyroid  and  cricoid  cartilages,  behind  the  articulation  of  these 
two  cartilages.  Lying  to  the  outer  side  of  these  structures  (larynx, 
trachea,  and  oesophagus)  are  the  common  carotid  artery,  with  the 
internal  jugular  vein  upon  its  outer  side,  and  the  pneumogastric 
nerve  between  them,  but  on  a  plane  posterior.  The  middle  thyroid 
vein  passes  outward  across  this  space  to  enter  the  internal  jugular 
vein,  passing  across  the  front  of  the  common  carotid  artery  to  reach 
its  destination. 

In  this  triangle  the  common  carotid  artery  and  the  internal 
jugular  vein  lie  beneath  the  anterior  border  of  the  sterno-mastoid 


1  The  thyro-hyoid  is  really  the  continuation  of  the  sterno-thyroid. 


SURGICAL  ANATOMY  OF  THE  NECK. 


129 


Fig.  77.— Side  of  Neck  to  Show  Triangles.  DA,  anterior  belly  of  the 
digastric;  DP,  posterior  belly  of  the  digastric;  EJ,  external  jugular  vein; 
F,  facial  vein;  EG,  hyo-glossus  muscle;  ET,  hypoglossal  nerve;  IJ,  internal 
jugular  vein;  M.E,  mylo-hyoid  muscle;  OEA,  anterior  belly  of  the  omo- 
hyoid; OEP,  posterior  belly  of  the  omo-hyoid;  PA,  post-auricular  vein;  PJ, 
posterior  jugular  vein;  8 A,  scalenus  anticus  muscle;  SC,  subclavian  artery; 
8.TT,  sterno-thyroid  muscle;  T,  temporal  vein. 


130  KECK  AND  TONGUE. 

muscle,  which  is  the  guide  to  them  and  which  must  be  drawn  out- 
ward (backward)  in  order  to  expose  them.  Lying  still  deeper  in  this 
part  of  the  neck,  beneath  the  carotid  artery  and  the  internal  jugular 
vein,  are  the  inferior  thyroid  artery,  which  passes  inward  and  upward 
behind  these  vessels  to  reach  the  lower  part  of  the  thyroid  gland, 
and  the  vertebral  artery,  which  enters  the  foramen  in  the  root  of 
the  transverse  process  of  the  sixth  cervical  vertebra.  The  sympa- 
thetic nerve  is  also  found  deep  in  this  space  behind  the  carotid 
vessels,  resting  upon  the  muscles  which  cover  the  front  of  the  ver- 
tebral column,  and  in  this  situation  it  presents  its  middle  cervical 
ganglion. 

The  Superior  Carotid  Triangle.  —  This  space  is  bounded 
behind  by  the  anterior  border  of  the  sterno-mastoid,  above  and  in 
front  by  the  posterior  belly  of  the  digastric  and  the  stylo-hyoid,  and 
below  and  in  front  by  the  anterior  belly  of  the  omo-hyoid.  The 
floor  of  this  space  is  formed  by  the  constrictor  muscles  of  the  phar- 
ynx and  the  thyro-hyoid  and  a  part  of  the  hyo-glossus  muscles.  It 
contains  the  upper  part  of  the  common  carotid  artery  and  its  bifur- 
cation into  the  internal  and  external  carotids,  which  division  occurs 
upon  a  level  with  the  upper  border  of  the  thyroid  cartilage.  The 
internal  jugular  vein  lies  in  close  contact  with  the  outer  side  of  the 
common  carotid  artery  and  its  continuation,  the  internal  carotid; 
and  the  pneumogastric  nerve  still  holds  its  place  between  the  artery 
and  vein,  but  on  a  plane  posterior  to  both. 

The  vessels  in  this  triangle  are  superficial,  not  being  covered 
by  the  anterior  edge  of  the  sterno-mastoid,  but  lying  anterior  to  it. 
The  edge  of  the  muscle  is  here  also  the  guide  to  the  vessels.  A 
chain  of  lymphatic  nodes  is  located  along  the  front  border  of  the 
sterno-mastoid  muscle,  and  some  of  them  are  in  very  close  proximity 
to  the  internal  jugular  vein. 

In  this  triangle,  the  external  carotid,  as  it  ascends  to  a  point 
behind  the  angle  of  the  jaw,  describes  a  slight  curve  with  the  con- 
vexity forward,  and  lies  rather  beneath  the  posterior  belly  of  the 
digastric  and  stylo-hyoid  and  upon  a  plane  anterior  to  the  internal 
carotid,  giving  off  several  important  branches:  among  them  the 
superior  thyroid,  which  passes  to  the  upper  part  of  the  thyroid 
gland;  the  lingual,  which  passes  forward  beneath  the  hyo-glossus 
muscle  to  supply  the  tongue;  and  the  facial,  which  passes  upward 
and  outward  over  the  lower  border  of  the  jaw.  The  occipital  and 
the  posterior  auricular  are  derived  from  the  posterior  aspect  of  the 


SURGICAL  ANATOMY  OF  THE  NECK.  131 

external  carotid  artery  and  ascend  in  a  direction  upward  and  back- 
ward. 

The  hypoglossal  nerve  arches  forward  across  the  external  carotid 
artery  upon  a  level  with  the  origin  of  the  occipital  artery. 

In  this  space  the  facial  vein  is  joined  by  a  large  branch  from 
the  temporo-maxillar}r,  and  then  passes  downward  and  outward 
across  the  external  carotid  and  internal  carotid  arteries  to  enter  the 
internal  jugular  vein.  This  vein  is  often  cut  during  extirpation  of 
glands  in  this  triangle  and  gives  rise  to  a  copious  hemorrhage,  which 
is  readily  controlled  by  pressure  with  the  finger  in  the  wound  and 
artery  forceps.  It  may  often  be  recognized  and  tied  double  before  it 
is  cut. 

The  Submaxillaky  Tkiangle. — The  submaxillary  triangle  is 
bounded  above  by  the  lower  border  of  the  jaw  and  an  imaginary  line 
drawn  from  the  angle  of  the  jaw  to  the  tip  of  the  mastoid  process, 
below  and  in  front  by  the  anterior  belly  of  the  digastric  muscle,  and 
below  and  behind  by  the  posterior  belly  of  the  digastric  and  the 
stylo-hyoid  muscle.  The  apex  of  the  triangle  corresponds  to  the 
attachment  of  these  muscles  to  the  hyoid  bone.  When  the  coverings 
of  this  triangle — consisting  of  the  skin,  subcutaneous  fat,  platysma, 
and  deep  fascia — are  reflected,  we  find  it  fairly  well  occupied  by  the 
submaxillary  gland,  which  rests  in  a  bed  of  loose  connective  tissue, 
and  various  lymph-nodes.  The  back  part  of  this  triangle  is  crossed 
by  the  facial  artery,  which  passes  upward  and  forward  over  the  upper 
border  of  the  submaxillary  gland  to  reach  the  lower  border  of  the 
jaw,  over  which  it  curves  on  to  the  side  of  the  face,  grooving  the 
bone  just  in  front  of  the  attachment  of  the  masseter  muscle.  The 
facial  vein,  which  lies  superficial  to  the  facial  artery,  after  receiving 
the  submental  vein,  also  crosses  the  posterior  part  of  the  submaxil- 
lary triangle,  passing  downward  and  backward  across  (superficial  to) 
the  posterior  belly  of  the  digastric  and  stylo-hyoid  muscles  and,  after 
uniting  with  a  large  branch  from  the  temporo-maxillary  vein  in  the 
upper  part  of  the  superior  carotid  triangle,  enters  the  internal 
jugular. 

After  the  submaxillary  gland  has  been  raised  out  of  its  bed,  its 
duct,  Wharton's,  may  be  seen  passing  forward  beneath  the  posterior 
edge  of  the  mylo-hyoid  muscle  to  open  anteriorly  in  the  floor  of  the 
mouth.  The  gland  may  be  isolated  and  cut  away  from  its  duct,  and 
then  the  floor  of  the  triangle  is  exposed  to  view.  The  floor  of  the 
triangle  is  formed,  for  the  most  part,  by  the  mylo-hyoid  muscle, 


132  NECK  AND  TONGUE. 

whose  fibers  have  an  oblique  direction,  and  the  hyo-glossus,  which 
lies  upon  a  deeper  plane  than  the  mylo-hyoid  and  forms  the  posterior 
part  of  the  floor  of  the  triangle;  the  fibers  of  the  hyo-glossus  muscle 
run  straight  up  and  down  from  the  hyoid  bone  to  the  under  surface  of 
the  tongue.  The  lingual  artery  lies  beneath  the  hyo-glossus  muscle. 
The  submental  branch  of  the  facial  artery  passes  forward  parallel 
with  and  close  to  the  inner  surface  of  the  body  of  the  jaw,  resting 
upon  the  mylo-hyoid  muscle.  The  hypoglossal  nerve  may  be  seen 
passing  forward,  entering  the  submaxillary  triangle  from  beneath  the 
posterior  belly  of  the  digastric  muscle.  In  the  triangle  this  nerve 
rests  upon  the  hyo-glossus  muscle,  disappearing  anteriorly  beneath 
the  posterior  border  of  the  mylo-hyoid  muscle.  Accompanying  the 
hypoglossal  nerve  is  the  lingual  vein,  which  passes  backward  and 
enters  the  facial. 

The  hypoglossal  nerve  forms  the  base  of  a  second  smaller  tri- 
angle, which  corresponds  to  the  apex  of  the  submaxillary  triangle 
and  which  is  called  the  lingual  triangle. 

The  Lingual  Triangle. — The  base  of  the  lingual  triangle, 
which  is  above,  is  formed  by  the  hypoglossal  nerve;  its  borders, 
anterior  and  posterior,  by  the  respective  bellies  of  the  digastric. 
The  apex  of  the  triangle  is  located  below  where  this  muscle  is  at- 
tached to  the  hyoid  bone.  The  floor  of  the  triangle  is  formed  by 
the  fibers  of  the  hyo-glossus  muscle.  Directly  beneath  this  muscle, 
in  the  space  marked  out  as  the  lingual  triangle,  the  lingual  artery 
is  located,  and  in  this  situation  it  is  very  readily  found  and  ligated. 
The  hyo-glossus  muscle  is  picked  up  with  mouse-tooth  forceps  and 
snipped  through,  when  the  lingual  artery  comes  into  plain  view  and 
may  be  easily  surrounded  with  a  ligature  in  a  carrier. 

The  Occipital  Triangle. — This  space  is  bounded  in  front  by 
the  posterior  border  of  the  sterno-mastoid,  behind  by  the  anterior 
border  of  the  trapezius,  and  below  by  the  posterior  belly  of  the  omo- 
hyoid. This  triangle  is  of  but  little  surgical  importance.  It  is  cov- 
ered by  the  skin,  superficial  fascia  (fat),  by  the  platysma  in  part, 
and  by  the  deep  cervical  fascia.  Beneath  the  deep  cervical  fascia 
there  is  a  mass  of  loose  fat.  Lying  upon  the  deep  fascia  (superficial 
to  it)  is  the  posterior  jugular  vein,  which,  below,  at  the  posterior 
border  of  the  sterno-mastoid  muscle,  joins  the  external  jugular.  A 
chain  of  lymphatic  nodes,  which  lie  along  the  posterior  border  of 
the  sterno-mastoid  in  this  triangle,  are  frequently  diseased  and  re- 
quire removal.     The  space  is  crossed  by  the  superficial  descending 


SURGICAL  ANATOMY  OF  THE  NECK.  133 

branches  of  the  cervical  plexus.  The  spinal  accessory  nerve  emerges 
from  the  posterior  border  of  the  sterno-mastoid,  at  the  junction  of 
its  upper  and  middle  thirds,  and  passes  obliquely  downward  and 
backward  across  this  space,  beneath  the  deep  cervical  fascia,  and 
disappears  under  the  anterior  border  of  the  trapezius  muscle,  which 
it  supplies.  The  floor  of  this  space  is  formed,  from  above  downward, 
by  the  splenius,  the  levator  anguli  scapula?,  and  the  middle  and 
posterior  scaleni. 

The  Subclavian  Tkiangle. — This  triangle  corresponds  to  the 
lower  part  of  the  posterior  triangle.  It  is  covered  by  the  skin,  fat, 
and  superficial  fascia,  the  platysma,  and  deep  cervical  fascia,  and  is 
crossed  by  the  superficial  descending  branches  of  the  cervical  plexus. 
In  the  front  part  of  this  space,  just  behind  the  posterior  border  of 
the  sterno-mastoid  muscle,  the  external  jugular  vein  pierces  the  deep 
cervical  fascia.  After  the  integument,  etc.,  including  the  deep  cer- 
vical fascia,  have  been  incised,  the  boundaries  of  the  subclavian  tri- 
angle may  be  sought  for.  These  are,  below,  the  clavicle;  in  front,  the 
posterior  border  of  the  sterno-mastoid  muscle;  and,  above,  the  poste- 
rior belly  of  the  omo-hyoid;  this  latter  muscle  lies  low  in  the  neck, 
close  to  the  clavicle,  and  in  order  to  demonstrate  the  triangle  it  may 
be  necessary  to  draw  it  somewhat  upward. 

Crossing  the  space  from  without  inward,  just  above  the  clavicle, 
are  the  transversalis  colli  and  suprascapular  veins;  these  form  a 
plexus  beneath  the  deep  cervical  fascia  and  terminate  in  the  ex- 
ternal jugular;  the  external  jugular  vein  enters  the  subclavian 
just  external  to  the  tendon  of  the  scalenus  anticus.  The  external 
jugular  vein,  after  piercing  the  deep  cervical  fascia  and  immedi- 
ately before  it  terminates  in  the  subclavian,  also,  as  a  rule,  receives 
the  anterior  jugular  vein.  This  latter  drains  the  front  of  the  neck, 
originating  above  in  the  hyoid  and  suprahyoid  regions.  In  the 
subclavian  triangle  there  is  also  found  (beneath  the  deep  cervical 
fascia)  a  mass  of  lymphatic  nodes,  fat,  and  loose  connective  tissue 
which  communicates  with  the  lymphatics  of  the  breast  and  axilla 
and  which  may  become  involved  in  disease  of  the  breast.  The  floor 
of  the  subclavian  triangle  is  formed  by  the  scalenus  anticus  and 
scalenus  medius  muscles.  In  order  to  expose  the  scalenus  anticus 
muscle,  the  sterno-mastoid,  which  conceals  it,  must  be  drawn  forward 
(inward).  When  the  scalenus  anticus  is  thus  exposed  the  phrenic 
nerve  may  be  seen  passing  obliquely  downward  and  inward  across 
its  anterior  surface,  descending  into  the  chest  across  the  front  of 


134  NECK  AND  TONGUE. 

the  first  part  of  the  subclavian  artery.  Beneath  the  venous  plexus 
above  mentioned,  and  lying  close  upon  the  muscles  that  form  the 
floor  of  the  triangle,  are  the  transversalis  colli  and  suprascapular 
arteries:  branches  from  the  first  part  of  the  subclavian.  Emerging 
from  between  the  scalenus  anticus  and  the  scalenus  medius  and 
passing  obliquely  downward  and  outward  are  the  three  cords  of  the 
brachial  plexus.  They  disappear  beneath  the  clavicle  into  the  axil- 
lary space.  The  third  part  of  the  subclavian  artery  is  found  below 
the  cords  of  the  brachial  plexus,  deep  in  the  subclavian  triangle, 
below  the  level  of  the  clavicle,  resting  in  the  groove  upon  the  upper 
surface  of  the  first  rib,  external  to  the  attachment  of  the  tendon  of 
the  scalenus  anticus.  The  tendon  of  the  scalenus  anticus  is  the 
guide  to  the  artery,  and  is  readily  recognized  in  the  inner  or  forward 
part  of  the  subclavian  triangle  as  a  tense  cord  and  may  be  followed 
downward  with  the  finger  as  far  as  its  attachment  to  the  first  rib. 
The  subclavian  vein  lies  some  distance  away  from  the  artery  in  front 
of,  and  internal  to  it,  the  artery  and  vein  being  separated  from  each 
other  by  the  tendon  of  the  scalenus  anticus. 

As  the  subclavian  artery  emerges  from  the  chest  it  arches  out- 
ward and  forward  to  reach  the  first  rib.  That  portion  of  the  sub- 
clavian which  lies  behind  the  tendon  of  the  scalenus  anticus  is  the 
second  part  of  the  artery;  the  part  which  lies  to  the  inner  side  of 
this  tendon  is  the  first  part;  and  that  which  lies  external  to  the 
tendon  of  the  scalenus  anticus,  resting  upon  the  upper  surface  of 
the  first  rib,  is  the  third  part  of  the  artery:  the  part  that  is  usually 
ligated.  The  second  and  first  parts  of  the  subclavian  artery,  the  parts 
behind  and  internal  to  the  tendon  of  the  scalenus  anticus,  are  in 
direct  relation  with  the  dome  of  the  pleura  and  the  apex  of  the 
lung,  which  projects  upward  into  the  root  of  the  neck,  beneath  the 
scaleni  muscles,  for  a  distance  of  3  to  3  1/2  cm.  above  the  level  of 
the  clavicle.  In  tying  the  third  part  of  the  subclavian  artery  one 
should  not  mistake  for  it  one  of  the  cords  of  the  brachial  plexus, 
which  lie  above.  The  artery  is  deep,  and  rests  directly  upon  the  first 
rib.  The  subclavian  vein  is  pretty  well  separated  from  the  artery, 
lying  in  front  of  and  internal  to  it  and  upon  a  rather  lower  level 
than  the  artery.  By  drawing  the  shoulder  down  we  depress  the 
clavicle,  and  may  thus  make  the  artery  more  accessible. 

The  Front  of  the  Neck. — This  part  of  the  neck  may  be  divided 
into  the  suprahyoid  region,  the  part  above  the  hyoid  bone,  and  the 
infrahyoid  region,  the  part  below  the  hyoid  bone.     The  infrahyoid 


SURGICAL  ANATOMY   OF  THE  NECK.  135 

region  presents  for  consideration  the  larynx,  trachea,  and  thyroid 
gland,  and  the  oesophagus,  which  lies  behind  these. 

The  Hyoid  Bone. — This  is  a  horseshoe-  or  U-  shaped  bone, 
with  a  body  and  two  lateral  horns,  which  are  prolonged  backward, 
one  on  either  side,  and  two  lesser  horns,  directed  upward. 

In  the  natural  position  of  the  head  the  hyoid  bone  is  on  a  level 
with  the  lower  border  of  the  inferior  maxillary  bone,  and  is  not  dis- 
tinctly recognized  until  the  head  is  thrown  back.  It  is  not  station- 
ary, but  may  be  said  to  be  about  opposite  the  fourth  cervical  ver- 
tebra. To  it  are  attached  numerous  muscles,  coming  from  different 
directions.  To  the  upper  surface  of  its  body  is  attached  the  base  or 
root  of  the  tongue;  from  its  lower  border  is  suspended  the  larynx. 
The  epiglottis  is  placed  behind  the  body  of  the  bone,  and  is  attached 
to  its  posterior  surface.  To  the  upper  surface  of  its  lateral  horn 
is  attached  the  middle  constrictor  of  the  pharynx,  and  it  thus  serves 
to  support  the  wall  of  the  pharynx  and  provide  a  fixed  point  for 
the  action  of  the  muscles  in  deglutition. 

Supkahyoid  Region. — This  is  the  space  between  the  hyoid  bone 
and  the  lower  border  of  the  jaw.  This  region  is  covered  with  skin, 
superficial  fascia  (fat),  platysma,  and  deep  fascia;  the  deep  fascia  is 
attached  to  the  body  and  cornua  of  the  hyoid  bone.  Beneath  the 
platysma,  between  it  and  the  deep  fascia,  are  several  venous  branches 
which  go  to  form  the  anterior  jugular.  Upon  removal  of  the  deep 
fascia  a  triangular  space  is  exposed:  the  submental  triangle.  The 
apex  of  this  triangle  corresponds  to  the  symphysis  of  the  lower  jaw, 
its  sides  to  the  anterior  belly  of  either  digastric,  and  its  base  to  the 
hyoid  bone.  Its  floor  consists  of  the  mylo-hyoid  muscle,  with  its 
raphe  in  the  middle  line.  This  space  contains,  beneath  the  deep 
fascia,  several  lymphatic  nodes,  which  are  occasionally  the  seat  of 
disease  and  may  demand  extirpation.  Beneath  the  mylo-hyoid,  upon 
either  side,  in  the  floor  of  the  mouth,  the  sublingual  glands  are 
lodged.  The  floor  of  this  space  is,  at  times,  cut  through  in  opera- 
tions upon  the  lower  jaw  and  in  order  to  reach  the  tongue. 

Infkahyoid  Region. — This  is  the  region  below  the  hyoid  bone. 
The  skin  is  but  loosely  attached  to  the  underlying  structures;  be- 
neath the  skin  are  fat  and  the  deep  cervical  fascia.  The  platysma 
is  not  met  with  in  this  part  of  the  neck.  Below  the  hyoid  bone  may 
be  felt  the  thyroid  cartilage,  that  of  either  side  uniting  in  the  middle 
line  to  form  the  prominence  "Adam's  apple."  The  Adam's  apple 
is  not  prominent  in  the  female  or  child,  and  is  not,  therefore,  a  good 


136  NECK  AND  TONGUE. 

surgical  guide.  Below  the  thyroid  the  cricoid  cartilage  may  be  felt. 
This  is  located  opposite  the  sixth  cervical  vertebra,  and  marks  the 
point   where   the   omo-hyoid  muscle   crosses   the   common   carotid 


Fig.  78.— Front  of  the  Neck.  CC,  cricoid  cartilage;  DA,  anterior  belly  of 
digastric;  H,  hyoid  bone;  MH,  mylo-hyoid  muscle;  SH,  sterno-hyoid  muscle; 
S.TY,  sterno-thyroid  muscle;  TO,  thyroid  cartilage;  TR,  trachea;  TY.Q, 
isthmus  of  thyroid  gland. 


SURGICAL  ANATOMY  OF  THE  NECK.  137 

artery.  The  cricoid  is  a  ring  of  cartilage  which  is  rather  narrow 
anteriorly,  but  of  considerable  breath  posteriorly;  it  is  always  very 
readily  felt,  and  is  therefore  a  good  guide.  From  the  cricoid  down 
to  the  upper  border  of  the  sternum  the  space  is  occupied  by  the  trachea. 
Just  below  the  cricoid  cartilage  the  isthmus  of  the  thyroid  gland  lies 
transversely  across  the  front  of  the  trachea,  each  lobe  of  the  gland 
extending  outward  and  upward  beneath  the  sterno-hyoid  and  sterno- 
thyroid muscles,  reaching  upward  upon  the  side  of  the  thyroid  carti- 
lage and  getting  into  close  proximity  to  the  common  carotid  artery  and 
its  adjoining  structures.  Between  the  cricoid  cartilage  and  the  isthmus 
of  the  thyroid  gland  there  is  usually  a  space  about  one-half  inch  wide. 
On  either  side  of  the  middle  line,  passing  from  the  hyoid  bone  and 
thyroid  cartilage  down  to  the  sternum,  are  two  long,  flat,  ribbon-like 
muscles,  one  superimposed  upon  the  other:  the  sterno-hyoid  and 
sterno-thyroid.  The  sterno-thyroid  lies  beneath  the  sterno-hyoid,  being 
partly  concealed  by  the  latter.  The  sterno-thyroid  is  attached  to  the 
side  of  the  thyroid  cartilage  and  does  not  reach  the  hyoid  bone,  but 
is  continuous  with  the  short  thyro-hyoid  muscle,  which  is  attached  to 
the  hyoid  bone.  The  inner  edges  of  these  muscles  do  not  meet  in  the 
middle  line  of  the  neck,  but  are  connected  with  each  other  through  the 
intervening  deep  cervical  fascia.  They  partly  cover  the  trachea  and 
sides  of  the  larynx  and  the  lateral  lobes  of  the  thyroid  gland.  Between 
the  edges  of  the  muscles,  in  the  middle  line,  from  above  downward,  and 
covered  only  by  the  interposed  deep  fascia,  are  the  thyroid  and  cricoid 
cartilages,  the  isthmus  of  the  thyroid  gland,  and  the  trachea. 

Between  the  hyoid  bone  and  the  upper  border  of  the  thyroid 
cartilage  there  is  a  space  which  is  filled  in  by  the  thyro-hyoid  mem- 
brane. This  membrane  is  pierced  on  either  side  by  the  superior  laryn- 
geal vessels  and  the  internal  laryngeal  branches  of  the  superior  laryn- 
geal nerve.  This  membrane  may  be  cut  in  attempts  at  suicide:  cut 
throat.  Between  the  lower  border  of  the  thyroid  cartilage  and  the 
upper  border  of  the  cricoid  there  is  also  a  space  which  is  filled  in  by  a 
membrane :  the  crico-thyroid.  This  may  also  be  divided  in  cut  throat. 
Above  the  hyoid  bone,  running  transversely  inward  and  anastomosing 
with  the  branch  of  the  opposite  side,  is  the  hyoid  branch  of  the  lingual 
artery.  Below  the  hyoid  bone  there  is  a  similar  transverse  branch,  the 
hyoid,  which  is  derived  from  the  superior  thyroid  and  which  passes 
likewise  inward,  anastomosing  across  the  middle  line  with  its  fellow 
of  the  opposite  side.  A  third  transverse  branch  passes  inward,  above 
the  cricoid  cartilage,  upon  the  membrane  between  the  lower  border  of 


138  NECK  AND  TONGUE. 

the  thyroid  cartilage  and  upper  border  of  the  cricoid  cartilage.  This 
is  the  crico-thyroid  branch  of  the  superior  thyroid  artery.  It  also 
anastomoses  with  its  fellow  of  the  opposite  side.  Below  the  level  of 
the  cricoid  cartilage  no  arterial  branches  cross  the  middle  line  except 
through  the  isthmus  of  the  thyroid  gland. 

The  oesophagus  lies  behind  the  trachea,  closely  applied  to  its 
posterior  wall,  and  when  empty  is  flattened  out  against  the  vertebrae. 
It  projects  a  considerable  distance  to  the  left  of  the  trachea,  and  is 
therefore  easier  to  reach  through  an  incision  upon  the  left  side  of  the 
neck  than  upon  the  right.  Above,  the  oesophagus  is  continuous  with 
the  pharynx,  into  the  commencement  of  which  the  larynx  opens,  the 
orifice  of  the  larynx  being  protected  by  the  overhanging  epiglottis, 
which  is  situated  below  and  behind  the  root  of  the  tongue.  The  poste- 
rior wall  of  the  larynx,  which  is  formed  by  the  broad  posterior  portion 
of  the  cricoid  cartilage,  is  in  close  relation  with  the  front  wall  of  the 
pharynx.  Only  a  thin  layer  of  connective  tissue  intervenes  between 
the  anterior  wall  of  the  pharynx,  which  consists  merely  of  a  layer  of 
mucous  membrane,  and  the  posterior  part  of  the  larynx,  which  is 
made  up  chiefly  of  the  broad  posterior  part  of  the  cricoid  cartilage. 
When  the  pharynx  is  empty  it  is  flattened  out  against  the  vertebral 
column,  and  the  larynx,  under  these  circumstances,  also  lies  close  to 
the  vertebral  column. 

From  the  cricoid  cartilage  down,  the  oesophagus  and  trachea, 
although  in  close  proximity  to  each  other,  form  two  distinct  tubes, 
which  may  be  readily  separated,  one  from  the  other.  The  posterior 
wall  of  the  trachea,  which  is  in  direct  relation  with  the  oesophagus, 
is  devoid  of  cartilaginous  bands,  and  therefore  a  foreign  body,  lodged 
in  the  oesophagus,  might  press  upon  this  contiguous,  non-cartilaginous 
portion  of  the  wall  of  the  trachea  and  cause  symptoms  of  strangula- 
tion. In  the  recess  between  the  trachea  and  oesophagus,  on  either  side, 
the  recurrent  laryngeal  nerve  ascends  to  enter  the  lower  back  part  of 
the  larynx. 

The  Lakyngeal  Eegiox  is  covered  in  front  by  skin  and  deep 
fascia,  but  laterally  by  the  muscles,  the  sterno-hyoid  and  sterno- 
thyroid and  thyro-hyoid,  and  by  the  lobes  of  the  thyroid  gland. 

The  interior  of  the  larynx  may  be  examined  after  splitting  the 
thyroid  cartilage,  taking  care  to  make  this  section  in  the  middle  line, 
between  the  anterior  attachments  of  the  vocal  cords.  The  true  and 
false  vocal  cords  are  then  exposed  to  view.  The  true  cords  are  the 
lower,  and  are  attached  anteriorly,  upon  either  side  of  the  middle 


SURGICAL  ANATOMY  OF  THE  NECK.  139 

line,  to  the  thyroid  cartilage,  midway  between  the  lowest  part  of  the 
incisura  in  its  upper  border  and  the  lower  border;  posteriorly  the 
true  vocal  cords  are  attached  to  the  arytenoid  cartilages,  which  rest, 
swivel-like,  upon  the  upper  surface  of  the  cricoid  cartilage. 

The  false  vocal  cords  are  the  loose  folds  of  mucous  membrane 
which  are  situated  above  the  true  cords,  inclosing  much  loose  con- 
nective tissue;  these  may  readily  become  cedematous — cedema  glottis 
— and  act  as  a  dangerous  obstruction  to  respiration. 

The  Thteoid  Glaxd. — The  isthmus  is  the  narrowest  part  of 
the  thyroid  gland.  It  joins  the  two  lobes  of  the  gland  across  the 
middle  line,  resting  transversely  upon  the  upper  part  of  the  trachea. 
At  times  there  projects  from  the  upper  border  of  the  isthmus  a  pro- 
cess of  glandular  tissue,  the  so  called  middle  or  pyramidal  lobe,  which 
is  located  in  front  of  the  larynx  and  which  may  be  encountered  in 
operations  in  this  locality.  The  thyroid  gland  is  inclosed  in  a  con- 
nective-tissue capsule.  Penetrating  into  the  substance  of  the  gland 
in  all  directions  are  connective-tissue  processes  or  septa  which  are 
given  off  from  the  capsule  and  which  support  the  parynchyma  divid- 
ing the  gland  into  lobes  and  lobules,  and  in  which  the  lymphatics 
course.  The  thyroid  gland  is  fixed  to  the  cricoid  and  thyroid  carti- 
lages by  bands  of  connective  tissue.  These  bands  connect  the  isth- 
mus of  the  gland  to  the  cricoid  cartilage  and  the  lateral  lobes,  ad- 
jacent to  the  isthmus,  to  the  sides  of  the  thyroid  cartilage.  It  is 
necessary  to  divide  those  bands  that  connect  the  isthmus  to  the 
cricoid  cartilage  before  the  isthmus  can  be  dislocated  downward  in 
order  to  expose  the  upper  rings  of  the  trachea  in  performing  the 
operation  of  high  tracheotomy.  The  two  lobes  of  the  thyroid  gland, 
one  on  each  side,  are  prolonged  backward  and  upward  upon  the  sides 
of  the  trachea  and  larynx,  reaching  as  far  back  as  the  oesophagus  and 
thus  getting  into  close  relationship  with  the  common  carotid  artery 
and  its  adjacent  structures.  As  the  recurrent  laryngeal  nerve  of 
each  side  ascends  between  the  trachea  and  oesophagus  to  enter  the 
lower,  posterior  part  of  the  larynx  it  lies  beneath  the  corresponding 
lateral  lobe  of  the  thyroid  gland  and  must  be  carefully  avoided  in 
operating,  etc.  The  isthmus  of  the  thyroid  lies  just  beneath  the  skin 
and  deep  fascia,  whereas  the  lateral  lobes  extend  upward  and  back- 
ward underneath  the  sterno-hyoid  and  sterno-thyroid  muscles. 

On  account  of  the  intimate  relationship  that  exists  between  the 
thyroid   gland   and   the   trachea,   tumors   involving  the   gland  may 


140  NECK  AND  TONGUE. 

press  upon  the  trachea  and  push  it  to  one  side;  so  that  if  trache- 
otomy becomes  necessary  in  these  cases  it  may  be  difficult  to  locate 
the  trachea.  When  the  thyroid  is  enlarged  by  tumors,  etc.,  it  may 
be  seen  to  rise  and  fall  with  the  larynx  in  movements  of  swallowing. 
The  thyroid  is  supplied  by  the  superior  and  inferior  thyroid  arteries 
of  each  side,  and  drained  by  the  superior,  middle,  and  inferior  thy- 
roid veins.  At  times  an  arterial  branch  from  the  transverse  portion 
of  the  arch  of  the  aorta  ascends  upon  the  front  of  the  trachea  to 
reach  the  lower  part  of  the  gland :   the  arteria  thyroidea  ima. 

The  Suprasternal  Kegion  is  the  space  in  the  lower  front  part 
of  the  neck  above  the  upper  border  of  the  sternum  and  limited  on 
either  side  by  the  anterior  border  of  the  sterno-mastoid.  The  sur- 
face shows  a  depression  here  known  as  the  suprasternal  fossa,  or 
fossa  jugularis.  This  region  is  covered  by  the  skin,  beneath  which 
lies  the  deep  cervical  fascia;,  which  splits  into  two  layers,  an  anterior 
and  a  posterior;  these  layers  are  attached  below  to  the  anterior  and 
posterior  edges  of  the  upper  border  of  the  sternum,  inclosing  a  space 
— the  suprasternal — between  them  which  is  occupied  by  some  con- 
nective tissue  and  lymphatic  glands.  A  communicating  venous 
branch  which  connects  the  anterior  jugulars  of  either  side  is  also 
included  between  these  two  layers.  The  suprasternal  space  is  shut 
off  from  the  mediastinum  by  the  posterior  layer  of  the  deep  cervical 
fascia,  and  pus  in  this  space  is  thus  hindered  from  breaking  into  the 
mediastinum  and  is  more  apt  to  open  externally  through  the  skin. 

Beneath  the  deep  fascia  lies  the  trachea,  its  anterior  surface 
being  readily  accessible  for  operation.  This  part  of  the  trachea  may 
be  lengthened  by  throwing  the  head  back.  If  the  trachea  is  incised 
transversely  the  wound  gapes,  and,  if  completely  severed  it  retracts  into 
the  chest  to  such  an  extent  that  it  may  be  difficult  or  impossible  to 
reunite  it.  At  times  the  arteria  thyroidea  ima  ascends  in  front  of  this 
lower  part  of  the  trachea  and  might  complicate  an  operation  upon  this 
part  of  the  tube. 

Descending  obliquely  downward  and  outward,  from  the  lower 
part  of  the  thyroid  gland,  are  the  inferior  thyroid  veins.  These 
enter  the  right  and  left  innominate  ve'ns  or  both  may  enter  the  left 
innominate,  within  the  chest,  behind  the  first  piece  of  the  sternum. 
The  inferior  thyroid  veins  are  large  and  lie  one  on  either  side  of 
the  middle  line.  As  they  descend  they  get  farther  away  from  the 
middle  line,  so  that  they  are  not  likely  to  be  encountered  in  the 


SURGICAL  ANATOMY  OF  THE  NECK.  141 

operation  of  low  tracheotomy  if  the  incision  is  kept  strictly  in  the 
median  line. 

The  Blood-vessels  of  the  Neck.  The  Common  Carotid  Artery. 
— This  vessel  ascends  in  the  neck  from  behind  the  sterno-clavicular 
articulation  to  the  level  of  the  upper  border  of  the  thyroid  cartilage, 
where  it  divides  into  the  external  and  internal  carotid.  The  course 
of  the  artery  is  indicated  by  a  line  drawn  from  the  sterno-clavicular 
articulation  to  a  point  midway  between  the  angle  of  the  jaw  and  the 
mastoid  process.  The  muscular  guide  to  the  artery  is  the  anterior 
border  of  the  sterno-mastoid. 

The  common  carotid  is  crossed  about  the  level  of  the  cricoid 
cartilage  by  the  omo-hyoid  muscle;  so  that  the  lower  part  of  the 
artery  lies  in  the  inferior  carotid  triangle  and  the  upper  part  in 
the  superior  carotid  triangle.  The  artery  is  more  accessible  for 
ligation  in  the  upper  triangle.  In  the  lower  part  of  its  course, 
below  the  omo-hyoid,  the  artery  lies  beneath  the  anterior  edge  of  the 
sterno-mastoid,  whereas  above,  in  the  superior  carotid  triangle,  it 
does  not  lie  beneath  the  edge  of  the  sterno-mastoid,  but  rather  in 
front  of  it,  and  is  here  quite  superficial,  being  covered  only  by  the 
integument,  platysma,  and  deep  cervical  fascia.  Opposite  the  thy- 
roid cartilage  the  lateral  lobe  of  the  thyroid  gland  comes  into  close 
relation  with  the  artery,  the  latter  grooving  the  gland.  In  its  course 
up  the  neck  the  artery  is  accompanied  by  the  internal  jugular  vein, 
which  lies  close  upon  its  outer  side,  and  by  the  pneumogastric  nerve, 
which  lies  between  the  vein  and  the  artery,  but  on  a  plane  posterior 
to  both.  These  structures  are  lodged  in  a  loose,  connective-tissue 
bed,  which  is  continuous  below  with  the  connective  tissue  of  the 
mediastinum. 

Upon  the  front  of  the  artery,  opposite  the  middle  of  the  thy- 
roid cartilage,  the  descendens  and  communicans  noni  form  a  loop 
from  which  some  branches  are  given  off  to  supply  the  depressor  mus- 
cles of  the  hyoid  bone.  Posteriorly  the  artery  rests  upon  the  trans- 
verse processes  of  the  lower  cervical  vertebras  and  the  attachments 
of  the  vertebral  muscles.  The  sympathetic  nerve  lies  behind  the 
artery  and  is  closely  related  to  the  fascia  that  covers  the  pre- 
vertebral muscles.  Below,  opposite  the  sixth  cervical  vertebra,  the 
inferior  thyroid  artery,  which  arises  from  the  first  part  of  the  sub- 
clavian, curves  inward,  behind  the  carotid,  etc.,  to  reach  the  lower 
part  of  the  thyroid  gland.     To  the  inner  side  of  the  artery  are  the 


142  NECK  AND  TONGUE. 

trachea  and  oesophagus,  and,  higher  up,  the  larynx  and  the  lower 
part  of  the  pharynx.  The  larynx  projects  forward  between  the 
arteries  of  either  side.  Ascending  between  the  trachea  and  the 
oesophagus  is  the  inferior,  recurrent,  laryngeal  nerve.  Opposite  the 
thyroid  cartilage  the  artery,  as  mentioned  above,  is  in  close  relation 
with  the  lateral  lobe  of  the  thyroid  gland.  Upon  the  outer  side  of 
the  artery  the  internal  jugular  vein  is  situated,  and  in  close  proxim- 
ity to  the  vein  a  chain  of  lymphatic  nodes.  The  common  carotid 
artery  is  crossed  above  the  omo-hyoid  muscle  by  the  superior  thyroid 
vein  and  about  its  middle — i.e.,  below  the  omo-hyoid — by  the  middle 
thyroid  vein.  Both  these  veins  terminate  in  the  internal  jugular. 
Lower  in  the  neck  the  artery  is  crossed  by  the  anterior  jugular  vein, 
which,  as  a  rule,  terminates  in  the  external  jugular. 

The  artery  is  covered  by  the  integument,  superficial  fascia, 
platysma,  and  deep  fascia.  The  lower  part  of  the  artery  lies  beneath 
the  sterno-mastoid,  and  this  muscle  must  therefore  be  drawn  aside 
in  order  to  expose  the  vessel.  Above,  upon  a  level  with  the  thyroid 
cartilage,  the  artery  lies  quite  superficial,  not  being  overlapped  by 
the  sterno-mastoid,  but  in  front  of  it  and  here  its  pulsation  may  be 
both  felt  and  seen. 

The  Internal  Carotid  is  continued  upward  in  the  same  course 
as  the  common  carotid,  lying  alongside  of  the  pharynx.  The  internal 
jugular  vein  lies  along  its  outer  side,  and  the  pneumogastric  nerve 
lies  between  both,  but  on  a  plane  posterior.  At  the  base  of  the  skull 
the  artery  enters  the  carotid  canal  in  the  petrous  portion  of  the 
temporal  bone,  and  after  traversing  this  canal  enters  the  cranium 
through  the  middle  lacerated  foramen.  In  the  neck  the  internal 
carotid  lies  in  the  superior  carotid  triangle,  covered  by  the  anterior 
edge  of  the  sterno-mastoid;  it  is  situated  deeper  than  the  external 
carotid  and  upon  a  plane  posterior  to  it.  The  stylo-glossus  and  stylo- 
pharyngeus  muscles,  as  they  pass  forward  to  the  tongue  and  to  the 
side  of  the  pharynx,  are  interposed  between  the  internal  and  ex- 
ternal carotids.  Behind,  the  artery  rests  upon  the  transverse  proc- 
esses of  the  upper  cervical  vertebras  and  upon  the  rectus  capitis 
anticus  major  muscle.  The  sympathetic  nerve,  with  its  superior 
ganglion,  lies  behind  the  artery,  between  it  and  the  anterior  ver- 
tebral muscles.  Internally  the  artery  is  in  relation  with  the  side  of 
the  pharynx.  The  superior  laryngeal  nerve  descends  between  it  and 
the  pharynx.  At  its  origin  the  artery  lies  quite  superficial,  being 
covered  by  the  integument,  platysma,  and  deep  fascia  and  over- 


SURGICAL  ANATOMY  OF  THE  NECK.  143 

lapped  by  the  anterior  margin  of  the  sterno-mastoid  muscle.  In  the 
upper  part  of  its  course  it  lies  deep  in  the  neck  beneath  the  poste- 
rior belly  of  the  digastric  and  stylo-hyoid  muscles  and  the  parotid 
gland  and  the  stylo-pharyngeus  and  stylo-glossus  muscles,  these  two 
latter  muscles  separating  it  from  the  external  carotid. 

At  the  base  of  the  skull  the  internal  jugular  vein  leaves  the  in- 
ternal carotid  artery  and  enters  the  skull  through  the  jugular  fora- 
men. This  foramen  is  located  external  and  posterior  to  the  opening 
which  marks  the  commencement  of  the  carotid  canal.  Just  below 
the  base  of  the  skull  the  glosso-pharyngeal  nerve  passes  forward  be- 
tween the  internal  jugular  vein  and  the  internal  carotid  artery  and 
then  continues  forward,  below  the  stylo-glossus  muscle,  to  reach  the 
side  of  the  base  of  the  tongue.  Just  above  the  level  of  the  hyoid 
bone  the  hypoglossal  nerve  curves  forward  between  the  artery  and 
the  vein.  The  spinal  accessory,  at  the  base  of  the  skull,  is  situated 
between  the  internal  carotid  artery  and  the  internal  jugular  vein, 
but  passes  backward  and  outward  to  reach  the  deep  surface  of  the 
sterno-mastoid  muscle. 

The  External  Carotid  Artery,  at  its  origin,  is  located  in  the 
superior  carotid  triangle  in  front  of  the  internal  carotid  artery.  It 
passes  upward  to  a  point  between  the  posterior  border  of  the  ramus 
of  the  jaw  and  the  mastoid  process,  and  here,  within  the  substance  of 
the  parotid  gland,  divides  into  the  temporal  and  internal  maxillary. 
As  it  ascends  upon  the  side  of  the  neck  it  describes  a  gentle  curve 
with  the  convexity  forward  and  is  placed  upon  a  plane  anterior  to  the 
internal  carotid,  giving  off  many  branches  to  the  muscles  and  struct- 
ures in  the  neck  and  to  the  tongue.  It  lies  in  front  of  the  anterior 
border  of  the  sterno-mastoid,  being  covered  only  by  the  skin, 
platysma,  and  deep  fascia;  higher  up,  on  a  level  with  the  angle  of 
the  lower  jaw,  it  is  covered  by  the  posterior  belly  of  the  digastric 
and  stylo-hyoid,  and  at  its  bifurcation  into  its  terminal  branches  it 
lies  deep  within  the  substance  of  the  parotid  gland. 

The  external  carotid  artery  does  not  lie  as  deep  in  the  neck  as 
the  internal  carotid;  upon  a  level  with  the  angle  of  the  lower  jaw 
thes.e  two  vessels  are  separated  from  each  other  by  the  stylo-glossus 
and  stylo-pharyngeus  muscles  (together  with  the  glosso-pharyngeal 
nerve).  Both  these  muscles  arise  from  the  styloid  process  and  pass 
forward,  between  the  external  and  internal  carotid  arteries,  in  their 
course  to  reach  the  side  of  the  tongue  and  the  pharynx. 

As  the  external  carotid  artery  lies  within  the  parotid  gland  it 


144  NECK  AND  TONGUE. 

is  crossed,  upon  a  level  with  the  lower  border  of  the  lobe  of  the  ear, 
by  the  divisions  of  the  facial  nerve.  The  temporo-maxillary  vein, 
which  is  formed  by  the  junction  of  the  temporal  and  internal  maxil- 
lary veins,  also  lies  superficial  to  it.  Below  the  angle  of  the  jaw 
the  artery  is  crossed  by  the  temporo-facial  vein;  this  vessel  is  formed 
by  the  facial  and  a  large  branch  from  the  temporo-maxillary,  and 
after  receiving  the  lingual  and  sometimes  the  superior  thyroid,  ter- 
minates in  the  internal  jugular. 

Below  the  level  of  the  hyoid  bone  the  external  carotid  gives  off 
the  superior  thyroid.  This  branch  passes  forward  and  downward  to 
the  lateral  lobe  of  the  thyroid  gland  and  gives  branches  to  the 
larynx.  The  next  branch  given  off  above  the  superior  thyroid  is  the 
lingual.  This  vessel  passes  forward,  beneath  the  digastric  and  stylo- 
hyoid muscles  and  beneath  the  hyo-glossus,  to  supply  the  tongue. 
The  next  branch  above  is  the  facial.  The  facial  is  directed  forward 
and  upward  and  curving  over  the  inferior  border  of  the  lower  jaw, 
in  the  groove  just  in  front  of  the  masseter  muscle,  ascends  upon 
the  side  of  the  face,  nose,  etc.  At  its  origin  the  facial  artery  lies 
beneath  the  posterior  belly  of  the  digastric  and  stylo-hyoid  mus- 
cles close  to  the  posterior  border  of  the  submaxillary  gland,  which 
it  grooves  and  supplies;  here  it  gives  off  its  submental  branch,  which 
runs  forward  upon  the  under  surface  of  the  mylo-hyoid  muscle 
close  to  the  body  of  the  lower  jaw.  From  its  posterior  aspect,  upon 
a  level  with  the  origin  of  the  facial,  the  external  carotid  artery  gives 
off  its  occipital  branch.  This  vessel  passes  upward  and  backward 
across  the  internal  jugular  vein  and  ascends  beneath  the  anterior 
border  of  the  sterno-mastoid  muscle  to  reach  the  occipital  region  of 
the  head.  Above  the  origin  of  the  occipital,  also  from  its  posterior 
aspect,  the  external  carotid  gives  off  the  posterior  auricular.  This 
vessel  courses  upward  and  backward,  running  close  behind  the  ear 
and  supplying  this  and  the  mastoid  region.  The  hypoglossal  nerve 
swings  forward  across  the  outer  side  of  the  external  carotid  artery 
upon  a  level  with  the  origin  of  the  occipital. 

The  Internal  Jugular  Vein  lies  close  to  the  outer  side  of 
the  common  carotid  artery  and  its  continuation,  the  internal  ca- 
rotid. This  vessel  is  large,  as  big  around  as  the  little  finger,  very 
thin  walled,  and  lies  in  the  same  connective-tissue  bed  with  the 
artery  and  the  pneumogastric  nerve.  It  is  formed  above,  at  the 
base  of  the  skull,  by  the  union  of  the  lateral  (sigmoid)  and  inferior 
petrosal  sinuses.     These  vessels  emerge  from  the  interior  of  the 


SURGICAL  ANATOMY   OF  THE  NECK.  145 

skull  through  the  jugular  foramen,  which  is  situated  behind  and 
external  to  the  commencement  of  the  carotid  canal;  the  pneumo- 
gastric,  spinal  accessory,  and  glosso-pharyngeal  nerves  also  emerge 
from  the  cranium  through  the  jugular  foramen.  Just  outside  the 
skull  the  lateral  and  the  inferior  petrosal  sinuses  join  and  form  a 
bulbous  dilatation,  which  marks  the  commencement  of  the  internal 
jugular  vein.  At  the  root  of  the  neck  the  internal  jugular  termi- 
nates by  joining  with  the  subclavian  to  form  the  innominate.  In  its 
course  through  the  neck  the  vein  receives  a  number  of  large 
branches:  the  temporo-facial,  lingual,  and  superior  and  middle  thy- 
roids. A  chain  of  lymphatic  nodes  is  situated  along  the  outer  side 
of  the  vein,  close  to  its  wall,  and  these  may  be  diseased  and  require 
extirpation.  On  the  right  side,  in  the  root  of  the  neck,  where  the 
internal  jugular  unites  with  the  subclavian,  the  right  lymphatic  duct 
is  seen  to  enter  the  vessel.  Upon  the  left  side  of  the  neck  the 
thoracic  duct  enters  the  vein  at  its  junction  with  the  subclavian; 
the  thoracic  duct  arches  over  the  third  part  of  the  subclavian  artery 
and  across  the  front  of  the  tendon  of  the  scalenus  anticus  in  order 
to  reach  the  vein. 

The  Subclavian  Artery. — This  vessel  upon  the  right  side  is 
derived  from  the  innominate,  which  bifurcates  behind  the  right 
sterno-clavicular  articulation  into  the  common  carotid  and  sub- 
clavian. The  left  subclavian  is  given  off  from  the  left  end  of  the 
transverse  part  of  the  arch  of  the  aorta  and  ascends  in  the  upper 
part  of  the  chest  as  far  as  the  left  sterno-clavicular  articulation. 

From  the  sterno-clavicular  articulation,  upon  either  side,  the 
subclavian  artery  arches  outward  across  the  root  of  the  neck  and 
passes  into  the  axilla  to  become  the  axillary.  In  the  root  of  the 
neck  the  artery  is  found  in  the  subclavian  triangle  resting  directly 
upon  the  first  rib. 

The  tendon  of  the  scalenus  anticus,  at  its  attachment,  is  situated 
in  front  of  the  subclavian  artery,  and  thus,  for  purposes  of  descrip- 
tion, serves  to  divide  the  vessel  into  three  parts.  The  first  part  of  the 
artery  corresponds  to  that  portion  which  is  included  between  its 
origin  and  the  inner  margin  of  the  tendon  of  the  scalenus  anticus; 
the  second  part  of  the  artery  corresponds  to  the  portion  immediately 
behind  the  tendon  of  the  scalenus,  and  the  third  part  of  the  artery 
reaches  from  the  outer  border  of  the  tendon  of  the  scalenus  anticus 
to  the  point  where  it  enters  the  axilla  to  become  the  axillary.  The 
first  and  second  parts  of  the  artery  are  in  intimate  relation  with  the 


146  NECK  AND  TONGUE. 

apex  of  the  lung  and  dome  of  the  pleura;  the  third  portion  rests 
upon  the  upper  surface  of  the  first  rib.  The  trunks  of  the  brachial 
plexus  in  their  course  through  the  subclavian  triangle  are  situated 
above  the  subclavian  artery.  The  subclavian  artery  gives  off  several 
large  branches;  from  its  first  part  the  vertebral,  internal  mammary, 
and  thyroid  axis  (inferior  thyroid,  suprascapular,  transversalis  colli); 
from  the  second  part,  the  superior  intercostal.  The  origin  of  these 
branches  varies  in  different  individuals  and  in  the  same  individual 
upon  either  side. 

The  subclavian  vein  is  the  continuation  of  the  axillary.  It 
passes  inward  across  the  root  of  the  neck,  beneath  the  clavicle  and  in 
front  of  the  scalenus  anticus  tendon,  resting  upon  the  upper  surface 
of  the  first  rib  and  lying  in  front  and  to  the  inner  side  of  the  artery. 
It  is  situated  a  considerable  distance  away  from  the  artery,  from 
which  it  is  separated  by  the  tendon  of  the  scalenus  anticus.  The 
subclavian  vein  joins  with  the  internal  jugular  to  form  the  innomi- 
nate. Upon  the  right  side  where  these  two  veins  join  they  receive 
the  right  lymphatic  duct,  and  upon  the  left  side,  at  their  junction, 
they  receive  the  thoracic  duct. 

The  Ineeeioe  Thyeoid  Aeteey  is  seen  deep  in  the  lower  part 
of  the  inferior  carotid  triangle.  It  is  a  branch  of  the  thyroid  axis 
which  arises  from  the  first  part  of  the  subclavian,  and  curves  upward 
and  inward,  passing  inward,  behind  the  common  carotid  artery,  about 
the  level  of  the  transverse  process  of  the  sixth  cervical  vertebra  in 
order  to  reach  the  lower  part  of  the  thyroid  gland.  As  this  vessel 
passes  behind  the  common  carotid  artery,  etc.,  it  is  crossed  from 
above  downward  by  the  sympathetic  nerve.  This  nerve  usually 
descends  in  front  of  the  inferior  thyroid  artery,  but  sometimes  be- 
hind it.  Just  before  the  artery  reaches  the  thyroid  gland  it  is  crossed 
by  the  recurrent  laryngeal  nerve,  which  ascends  in  the  space  between 
the  trachea  and  the  oesophagus  to  reach  the  larynx. 

The  Vertebeal  Aetery  lies  deep  in  the  lower  part  of  the 
neck.  It  arises  from  the  first  part  of  the  subclavian  between  the 
scalenus  anticus  muscle  in  front  and  the  longus  colli  behind  and 
enters  the  foramen  in  the  base  of  the  transverse  process  of  the  sixth 
cervical  vertebra.  The  prominent  tubercle  on  the  transverse  process 
of  this  vertebra  is  a  good  guide  to  the  artery.  The  artery  may  be 
reached  through  the  subclavian  triangle  by  drawing  the  sterno- 
mastoid  forward  toward  the  middle  line  or  by  nicking  or  incising  its 
posterior  border. 


OPERATIONS  UPON  THE  NECK.  147 

OPERATIONS  UPON  THE  NECK. 

Tracheotomy  means  opening  into  the  air-passage  either  for 
relief  when  obstruction  exists  or  as  a  preliminary  step  to  other  op- 
erations; for  example,  extirpation  of  the  larynx,  amputation  of  the 
tongue,  etc. 

In  1869,  as  a  preliminary  to  excision  of  the  jaw,  Nussbaum  per- 
formed a  tracheotomy  and  tamponed  the  pharynx  with  a  compress 
to  prevent  blood  from  entering  the  larynx  during  the  operation,  the 
anesthetic  being  administered  through  the  tracheotomy  tube. 

Tampon  of  the  Teachea. — Trendelenburg  uses  a  tracheotomy 
tube  which  is  surrounded  by  a  thin,  balloon-like  structure  provided 
with  a  cannula  so  that  it  may  be  inflated  after  it  has  been  introduced 


Fig.  79.— Tracheotomy  Tube.  Fig.  80.— Trendelenburg  Tampon  Can- 

nula. T,  tube  to  inflate  balloon.  Anaes- 
thetic is  given  through  a  long  tube  and 
funnel  attached  to  tracheotomy  tube. 


into  the  trachea,  in  this  way  plugging  the  trachea  and  preventing  the 
entrance  of  blood,  etc.  The  anesthetic  is  administered  through  the 
tracheotomy  tube,  to  which  a  long  rubber  tube  provided  with  a  fun- 
nel is  attached;  in  the  bottom  of  the  funnel  there  is  a  wad  of  cotton 
upon  which  the  anesthetic  is  dropped.  The  tracheotomy  tube  and 
tampon  may  be  allowed  to  remain  in  the  trachea  for  seven  or  eight 
days  after  the  operation. 

The  Site  of  Operation. — The  opening  into  the  air-passage 
may  be  made: — 

1.  Through  the  trachea  above  the  isthmus  of  the  thyroid  gland 
(high  tracheotomy).  This  is  the  preferable  operation  and  usually 
includes,  in  addition,  division  of  the  cricoid  cartilage  (crico-trache- 
otomy). 


148  NECK  AND  TONGUE. 

2.  Through  that  part  of  the  trachea  which  is  covered  by  the 
isthmus  of  the  thyroid  gland  (median  tracheotomy). 

3.  Through  the  trachea  below  the  isthmus  of  the  thyroid  gland 
(low  tracheotomy).  This  operation  is  rather  less  preferable,  because 
at  this  level  the  trachea  lies  deeper — farther  away  from  the  surface, 
and,  besides,  one  may  meet  the  inferior  thyroid  veins  or  some  of 
their  branches  or  there  may  be  an  arteria  thyroidea  ima  present. 
This  is  the  site  usually  selected  for  a  preliminary  tracheotomy  in 
conjunction  with  operations  upon  the  larynx;  for  example,  extirpa- 
tion of  the  larynx. 

4.  Through  the  crico-thyroid  membrane.  This  is  really  a  laryn- 
gotomy,  but  it  is  well  to  include  it  with  the  tracheotomies. 

High  Tracheotomy  (Crico-tracheotomy). — This  is  the  op- 
eration usually  performed,  and  has  the  advantage  that  no  vessels 
of  moment  are  met  with ;  and  that  this  part  of  the  air-tube  is  located 
quite  superficially,  near  the  surface. 

The  patient  lies  upon  the  back  with  the  shoulders  raised  and  the 
head  thrown  back.  If  the  symptoms  of  suffocation  are  urgent,  one 
may  dispense  with  an  anaesthetic  or  may  give  simply  a  few  whiffs 
of  chloroform.    The  operation  may  be  done  under  cocain  anaesthesia. 

By  palpation,  the  ring-like  cricoid  cartilage,  which  is  the  best 
landmark,  is  readily  located.  In  men  the  prominent  thyroid  carti- 
lage may  be  felt  and  seen  as  Adam's  apple,  but  in  women  and  chil- 
dren this  is  not  prominent  and  is  not,  therefore,  a  good  guide. 

An  incision  is  made  through  the  skin  and  subcutaneous  fat  from 
the  lower  border  of  the  thyroid  cartilage — just  above  the  cricoid — 
downward,  in  the  middle  line  of  the  neck,  for  a  distance  of  one  and 
one-half  inches.  In  making  this  skin  incision  some  small  tributaries 
of  the  anterior  jugular  vein  may  be  encountered;  to  these  clamps 
are  applied  and  the  skin  retracted,  exposing  thus  the  deep  cervical 
fascia  which  unites  the  edges  of  the  sterno-hyoid  muscles  of  either 
side  with  each  other.  This  layer  of  fascia  is  incised  along  the  middle 
line,  corresponding  to  the  incision  in  the  integument.  The  edges  of 
the  wound  being  now  retracted,  there  are  exposed,  above  the  cricoid 
cartilage  and  just  below  the  cricoid,  lying  transversely  across  the 
front  of  the  trachea,  the  isthmus  of  the  thyroid  gland.  The  isthmus 
of  the  thyroid  gland  is  located  about  one-half  inch  below  the  cricoid 
cartilage  to  which  it  is  connected  by  a  process  of  the  deep  cervical 
fascia.  This  slip  of  fascia  covers  or  conceals  the  upper  two  rings 
of  the  trachea;    so  that,  in  order  to  expose  these,  it  is  necessary  to 


OPERATIONS  UPON  THE  NECK.  149 

pick  up  this  band  and  snip  it  transversely,  after  which  the  isthmus 
may  be  drawn  downward  and  the  upper  rings  of  the  trachea  exposed 
to  view. 

The  next  step  is  to  enter  the  air-passage,  but  before  doing  this 
all  bleeding  points  should  be  clamped.  At  times,  during  the  opera- 
tion, the  larynx  moves  violently  up  and  down  in  forced  efforts  at 
respiration,  and  in  order  to  steady  it  a  tenaculum  must  be  employed. 
This  is  introduced  into  the  larynx  above  the  cricoid  cartilage,  pierc- 
ing the  crico-thyroid  membrane,  and  hooks  the  cricoid  cartilage 
firmly  upon  its  posterior  aspect  a  little  to  the  right  of  the  middle 
line.  The  operator  holds  this  tenaculum  with  the  left  hand,  thus 
steadying  the  larynx  and  trachea,  and,  with  a  sharp-pointed  knife 
held  short  in  the  right  hand,  the  cricoid  and  one  or  two  upper  rings 
of  the  trachea  are  cut  deliberately  from  above  downward.  One 
guards  the  knife  blade  in  order  to  avoid  injuring  or  perforating  the 
posterior  wall  of  the  trachea.  Having  made  an  opening  in  the  air- 
tube  about  one-half  inch  long  and  still  retaining  the  tenaculum 
which  was  hooked  into  the  cricoid  to  the  right  of  the  middle  line, 
a  second  tenaculum  is  now  hooked  into  the  other  side  of  the  cricoid, 
to  the  left  of  the  middle  line,  and  the  incision  in  the  air-passage 
thus  held  open  while  the  tube  is  being  introduced. 

Occasionally  the  thyroid  gland  has  a  well-marked  middle  lobe 
occupying  the  site  of  the  isthmus  and  ascending  upon  the  front  of 
the  cricoid.  This  extra  lobe  is  seldom  present,  but,  when  it  is,  it 
must  be  dislocated  downward  in  order  to  expose  the  cricoid  and  the 
upper  part  of  the  trachea.  Usually  it  is  not  necessary  to  apply  any 
ligatures  as  the  cut  vessels  cease  bleeding  after  a  few  minutes'  ap- 
plication of  the  artery  forceps;  still,  if  any  spurting  vessels  are  met, 
they  should  be  ligated.  The  edges  of  the  skin  may  be  brought  to- 
gether with  two  interrupted  catgut  sutures,  one  above  and  the  other 
below  the  tube. 

The  tube  is  held  in  place  by  a  tape  tied  around  the  neck  and 
the  wound  dressed  with  gauze  packed  loosely  about  the  wound  and 
the  tube. 

Low  Tracheotomy. — The  opening  is  made  into  the  trachea 
below  the  isthmus  of  the  thyroid  gland.  This  is  not  usually  the  site 
of  choice,  although  it  is  at  times  indicated.  This  part  of  the  trachea 
lies  farther  away  from  the  surface,  deeper,  and  one  may  meet  the 
inferior  thyroid  veins,  which  descend  in  front  of  the  trachea,  al- 
though they  usually  lie  well  to  either  side  of  the  middle  line,  thus 


150  NECK  AND  TONGUE. 

leaving  the  line  of  incision  free.  At  times  there  is  an  arteria  thy- 
roidea  ima  ascending  in  front  of  this  part  of  the  trachea:  a  rather 
unusual  condition. 

The  incision,  in  the  middle  line  of  the  neck,  commences  above 
at  a  point  just  below  the  cricoid  cartilage,  and  is  continued  down- 
ward toward  the  sternum,  for  a  distance  of  one  and  one-half  to 
two  inches.  The  incision  penetrates  first  through  the  skin  and  fat, 
and  is  then  continued  deeper  through  the  deep  cervical  fascia,  ex- 
posing the  front  of  the  trachea.  After  the  trachea  has  been  exposed 
all  bleeding  points  must  be  clamped;  usually  the  hemorrhage  is  only 
venous  and  ceases  after  the  artery  forceps  have  been  applied  for  a 
few  minutes.  The  operator  is  now  ready  to  make  the  opening  in 
the  trachea,  which  should  be  placed  below  the  level  of  the  isthmus 
of  the  thyroid  gland;  the  isthmus  may  be  drawn  upward  toward 
the  cricoid  cartilage  in  order  to  give  more  room.  All  bleeding  should 
be  controlled  before  the  trachea  is  opened. 

Before  making  the  incision  in  the  trachea  a  tenaculum  is  intro- 
duced into  the  trachea,  just  below  the  isthmus  of  the  thyroid  gland 
and  a  little  to  one  side  of  the  middle  line,  to  steady  the  trachea,  and 
with  a  sharp-pointed  knife,  held  short  by  the  blade,  an  incision  is 
made  into  the  trachea  from  below  upward,  cutting  two  or  three 
rings.  Still  steadying  the  trachea  with  the  first  tenaculum,  a  second 
tenaculum  is  introduced  into  the  incision  in  the  trachea,  and  while 
it  is  thus  held  open  the  tube  is  introduced.  The  tenacula  are  not 
withdrawn  until  the  tube  is  in  the  trachea. 

Any  spurting  vessels  or  large  veins  may  be  ligated,  and  one  or 
two  stitches  may  be  taken  in  the  skin  wound.  The  left  innominate 
vein  is  not  in  danger  if,  in  incising  the  trachea,  the  knife  is  not 
carried  below  the  level  of  the  sternum. 

Median  Tkacheotomy. — The  opening  into  the  trachea  is  made 
beneath  the  isthmus  of  the  thyroid  gland,  which  is  divided  in  order 
to  expose  this  part  of  the  trachea.  This  operation  can  be  done 
rapidly. 

The  incision  passes  through  the  skin  and  fat  and  reaches  from 
the  cricoid  cartilage  downward,  in  the  middle  line  of  the  neck,  for 
a  distance  of  one  and  one-half  to  two  inches.  The  incision  is  then 
carried  deeper  through  the  deep  fascia,  between  the  edges  of  the 
sterno-hyoid  muscles,  when  the  isthmus  of  the  thyroid  gland  is  ex- 
posed. The  isthmus  is  divided  and  the  trachea  recognized.  In 
dividing  the  isthmus  we  cut  several  venous  branches    which  bleed 


OPERATIONS  UPON  THE  NECK.  151 

and  must  be  clamped.  The  bleeding  should  be  controlled  before  the 
trachea  is  opened.  Bleeding  points  may  be  clamped  and  their  liga- 
tion postponed  until  after  the  tube  has  been  introduced  into  the 
trachea  if  time  is  limited.  The  trachea  is  steadied  with  a  tenaculum 
and  incised,  and  the  tube  introduced,  as  in  the  foregoing  operation. 

Transverse  Laryngotomy. — This  is  an  emergency  operation 
and  may  be  rapidly  performed.  The  windpipe  is  opened  after 
locating  the  cricoid  cartilage  and  using  this  as  a  guide,  by  cutting 
transversely  through  the  skin  and  crico-thyroid  membrane:  i.e., 
between  the  upper  border  of  the  cricoid  and  the  lower  border  of  the 
thyroid  cartilage.  There  is  some  probability  of  wounding  the  crico- 
thyroid artery,  a  small  branch,  yet  this  is  not  very  likely  as  the  in- 
cision is  made  transversely:    parallel  with  the  course  of  the  artery. 

Thyrotomy. — Division  of  the  thyroid  cartilage  may  be  either 
incomplete  or  complete. 

Incomplete  Thyrotomy. — The  incision  is  placed  in  the  middle 
line  of  the  neck  and  commences,  above,  at  a  point  just  below  the 
upper  border  of  the  thyroid  cartilage,  and  is  continued  downward 
to  a  point  just  below  the  cricoid  cartilage;  it  is  about  one  and  one- 
half  to  two  inches  long  and  reaches  through  the  skin  and  deep 
fascia,  exposing  the  cricoid  and  thyroid  cartilages.  The  edges  of  the 
wound  are  retracted  and  the  crico-thyroid  membrane  incised,  thus 
entering  the  larynx.  In  incising  the  crico-thyroid  membrane  the 
crico-thyroid  branches  may  be  cut;  these  are  small  branches,  but 
they  should  be  clamped  if  they  bleed,  as  even  a  small  quantity  of 
blood  sucked  into  the  wind-pipe  may  seriously  embarrass  respira- 
tion. We  then  proceed  to  enlarge  the  opening  into  the  larynx  by 
dividing  the  cricoid  cartilage  and  the  lower  part  of  the  thyroid 
cartilage,  to  an  extent  sufficient  to  permit  the  extraction  of  foreign 
bodies,  etc.  One  should  avoid,  if  possible,  incising  the  thyroid  carti- 
lage beyond  the  level  at  which  the  true  vocal  cords  are  attached. 

If  this  operation  is  done  for  the  removal  of  a  foreign  body,  one 
may  close  the  opening  in  the  larynx  and  omit  the  introduction  of  a 
tube;  still  it  is  probably  not  unwise  to  insert  the  tube  and  leave  it 
for  a  few  days  in  all  cases,  because,  as  a  result  of  the  operation,  there 
may  be  some  oedema  of  the  glottis  caused. 

Complete  Thyrotomy  consists  of  a  median  section  through  the 
thyroid  cartilage.  This  operation  is  done  for  the  purpose  of  ex- 
ploring the  interior  of  the  larynx  and  for  the  removal  of  foreign 
bodies,  growths,  etc. 


152  NECK  AND  TONGUE. 

During  the  operation  the  trachea  must  be  kept  clear  of  blood. 
The  operation  should  be  performed  with  the  patient  in  the  Eose 
position  unless  a  tampon  cannula  is  used,  when  the  patient  may  be 
placed  in  the  usual  tracheotomy  position  with  the  shoulders  raised 
and  the  head  thrown  back.  The  tampon  cannula  may  be  introduced 
through  a  preliminary  high  tracheotomy  done  at  the  same  sitting, 
previous  to  opening  the  larynx,  or  else  the  cannula  may  be  inserted 
through  the  incision  that  is  made  in  the  larynx  and  which  may  be 
prolonged  downward,  through  the  cricoid  and  upper  rings  of  the 
trachea  for  this  purpose.  Instead  of  a  high  tracheotomy,  a  prelimi- 
nary low  tracheotomy  may  be  performed  and  the  tampon  cannula 
introduced  at  this  point. 

The  incision  is  placed  in  the  middle  line  of  the  neck,  reaching 
from  the  hyoid  bone,  above,  to  a  point  below  the  level  of  the  cricoid 
cartilage.  The  incision  extends  through  the  skin  and  deep  fascia 
and  exposes  the  thyroid  cartilage. 

The  next  step  is  to  open  the  larynx.  The  point  of  the  knife 
is  introduced  through  the  crico-thyroid  membrane  between  the 
cricoid  and  the  lower  border  of  the  thyroid  cartilage.  In  doing  this 
the  crico-thyroid  branch  may  be  cut  and  should  be  clamped  and  tied. 
Then,  with  a  curved  probe-pointed  knife  which  is  introduced  into 
the  larynx  and  passed  upward  between  and  beyond  the  vocal  cords 
the  thyroid  cartilage  is  split  into  its  two  halves  from  within  outward, 
in  the  middle  line,  throughout  its  entire  length  up  to  or  into  the 
thyro-hyoid  membrane.  The  thyroid  cartilage  may  also  be  divided 
from  without  inward.  At  times  the  thyroid  cartilage  is  ossified,  and 
a  strong  scissors  or  thin  saw  is  necessary  in  order  to  accomplish  its 
division. 

After  the  thyroid  cartilage  has  been  split  its  edges  are  held 
apart  with  sharp  retractors  or  tenacula,  and  the  interior  of  the 
larynx  may  then  be  freely  explored.  We  may,  in  addition,  divide  the 
cricoid  cartilage  and  the  upper  rings  of  the  trachea  if  this  has  not 
already  been  done  or  if  more  room  is  required  or  in  order  to  intro- 
duce a  tampon  cannula. 

In  cutting  into  the  thyro-hyoid  membrane  one  should  avoid  the 
superior  laryngeal  vessels  and  nerve,  which  pierce  this  membrane 
upon  either  side  to  enter  and  supply  the  larynx. 

It  may  not  be  necessary  to  suture  the  two  halves  of  the  thyroid 
cartilages,  as  these  often  adapt  themselves  very  well  without  suture, 
especially  if  the  cricoid  cartilage  has  not  been  divided.    It  is  probably 


OPERATIONS  UPON  THE  NECK.  153 

wise,  however,  'in  all  cases,  to  introduce  two  or  three  chromicized 
catgut  sutures  through  the  perichondrium  to  hold  the  edges  of  the 
two  halves  of  the  thyroid  cartilage  in  contact  or  one  silver  wire 
suture  may  he  passed  through  each  edge  of  the  cartilage.  The  in- 
cision in  the  skin  may  he  partly  closed  with  catgut  sutures. 

The  tampon  cannula,  if  used,  may  be  left  in  place  for  a  few 
days  if  it  is  well  borne,  as  it  prevents  the  entrance  of  blood  and  dis- 
charges into  the  trachea  and  lungs. 

Laryngectomy  (Extirpation  of  the  Larynx).  —  This  operation 
should  be  preceded  by  a  low  tracheotomy,  which  may  be  done  a  week 
or  more  in  advance  of  the  major  operation  in  order  to  accustom  the 
patient  to  the  presence  of  the  tube  and  to  bring  about  fixation  of 
the  trachea  to  the  skin,  etc.,  of  the  neck. 

If  the  preliminary  tracheotomy  has  not  been  done,  the  operation 
should  be  performed  with  the  patient  in  the  Eose  position,  or,  if  the 
operation  is  done  with  the  patient  in  the  customary  tracheotomy 
position,  it  will  be  necessary,  as  soon  as  the  larynx  has  been  isolated 
and  all  the  vessels  that  supply  it  ligated,  to  cut  the  larynx  away  from 
the  trachea  below  and  then,  at  once,  introduce  the  tampon  cannula 
into  the  upper  end  of  the  trachea.  The  preliminary  tracheotomy, 
with  the  introduction  of  the  tampon  cannula,  is  probably  the  most 
preferable  plan. 

The  incision  is  made  in  the  middle  line  from  the  hyoid  bone  to 
a  point  below  the  cricoid  cartilage;  to  this  incision  a  second  trans- 
verse incision  may  be  added  which  extends  outward,  parallel  with 
the  hyoid  bone,  between  the  hyoid  bone  and  upper  border  of  the 
thyroid  cartilage,  as  far  as  the  anterior  border  of  "the  sterno-mastoid 
muscle  of  each  side,  thus  making  a  T-shaped  incision.  This  latter 
supplementary  incision  is  especially  advantageous  if  the  lymphatic 
glands,  etc.,  are  involved  in  the  pathological  process.  The  incision 
extends  through  the  skin  and  subcutaneous  fat  and  deep  cervical 
fascia,  and  exposes  the  thyroid  cartilage. 

The  edges  of  the  sterno-hyoid  muscles  are  next  recognized  and 
the  muscle  of  either  side  divided  transversely  either  partially  or 
completely.  The  parts  being  now  retracted,  we  expose  the  sterno- 
thyroid and  thyro-hyoid  muscles,  which  are  attached  upon  either  side 
of  the  thyroid  cartilage,  the  lateral  lobes  of  the  thyroid  gland  being 
situated  beneath  the  sterno-thyroid  muscles. 

We  now  begin  the  isolation  of  the  larynx,  separating  all  the 
soft  parts  either  with  an  elevator  or  with  the  knife,  the  edge  of  the 


154  NECK  AND  TONGUE. 

instrument  working  close  to  the  surface  of  the  thyroid  cartilage.  If 
the  elevator  is  used,  this  is  pushed  under  the  thyro-hyoid  muscle, 
between  it  and  the  thyroid  cartilage,  and  the  muscle  separated  from 
the  side  of  the  thyroid  cartilage,  detaching  the  sterno-thyroid  at  the 
same  time;  the  separation  of  these  muscles  may  he  accomplished  in 
part  with  the  knife.  These  two  muscles  are  really  one  and  the  same 
continuous  muscle ;  so  that,  after  they  have  been  detached  from  the 
thyroid  cartilage  they  hang  together  as  one  continuous  flat  band. 
Instead  of  detaching  these  muscles  as  described  they  may  be  simply 
cut  away  from  the  sides  of  the  thyroid  cartilage  with  the  knife. 
The  soft  parts  are  then  retracted  and  a  tenaculum  is  hooked  into  the 
side  of  the  thyroid  cartilage,  and  with  this  the  larynx  is  drawn  for- 
ward and  to  one  side,  so  that  we  are  enabled  to  reach  the  superior 
laryngeal  artery  and  its  accompanying  nervous  branch,  as  they  pierce 
the  side  of  the  thyro-hyoid  membrane  to  enter  the  larynx;  the  vessel 
is  tied  double  and  cut.  The  lateral  lobe  of  the  thyroid  gland,  which 
lies  upon  the  side  of  the  larynx  (in  the  natural  relation  of  the  parts 
being  covered  by  the  sterno-thyroid  muscle),  is  readily  separated 
from  the  side  of  the  larynx  with  the  elevator  or  the  finger.  At  this 
stage  of  the  operation  the  superior  thyroid  artery,  which  ramifies 
upon  the  upper  front  surface  of  the  thyroid  gland,  is  usually  met 
with.  This  vessel  need  not  be  cut.  The  thyroid  isthmus  is  also 
liberated  from  its  attachment  to  the  cricoid  cartilage  and  pushed 
downward  out  of  the  way. 

The  crico-thyroid  branch  of  the  superior  thyroid,  which  runs 
forward  and  inward  transversely  across  the  crico-thyroid  membrane, 
may  be  cut  and  should  be  clamped  and  tied.  There  is  also  an  in- 
ferior laryngeal  branch,  from  the  inferior  thyroid,  which  accom- 
panies the  inferior  laryngeal  nerve  into  the  larynx;  it  enters  the 
lower  back  part  of  the  larynx,  behind  the  articulation  between  the 
cricoid  and  thyroid  cartilages,  beneath  the  lateral  lobe  of  the  thy- 
roid gland;  this  branch  may  be  cut  and  should  be  tied.  The  small 
transverse  branch,  from  the  superior  thyroid,  which  runs  transversely 
inward  across  the  thyro-hyoid  membrane,  below  the  hyoid  bone,  to 
anastomose  with  its  fellow  of  the  opposite  side,  is  also  cut  and  tied. 

The  larynx  is  drawn  toward  the  opposite  side  and  the  above  de- 
scribed procedures  are  repeated  upon  the  other,  the  remaining,  side. 

The  isolation  of  the  larynx  is  continued.  The  soft  parts  are 
strongly  retracted  to  one  side  and  with  a  sharp  hook  or  volsella  the 
larynx  is  drawn  to  the  opposite  side;   then,  with  the  knife,  the  in- 


OPERATIONS  UPON  THE  NECK.  155 

ferior  constrictor  of  the  pharynx  is  separated  from  the  side  of  the 
thyroid  cartilage.  This  muscle  is  attached  upon  the  side  of  the 
thyroid  cartilage  close  to  its  posterior  border  which  may  be  readily 
felt  by  the  fingers  in  the  wound.  This  muscle  is  separated  from  the 
cricoid  cartilage  also.  Care  should  be  exercised  to  work  close  to  the 
surface  of  the  cartilage  in  separating  this  muscle  so  as  to  avoid 
opening  into  the  pharynx,  and  also  to  avoid  division  again  of  the 
vessels  that  have  already  been  divided  and  tied.  The  parts  are  then 
separated  in  a  similar  manner  upon  the  other  side  of  the  larynx  and 
we  are  ready  for  the  final  step  of  this  part  of  the  operation:  the 
separation  of  the  larynx  from  the  hyoid  bone  above,  from  the  ante- 
rior wall  of  the  pharynx  behind,  and  from  the  trachea  below. 

The  knife  is  introduced  through  the  thyro-hyoid  membrane  be- 
tween the  thyroid  cartilage  and  the  hyoid  bone,  and  this  membrane 
is  cut  in  a  direction  outward  and  backward,  at  the  same  time  draw- 
ing the  side  of  the  larynx  forward  with  a  sharp  hook  or  volsella. 
In  performing  this  step  of  the  operation  we  should  avoid  again  cut- 
ting the  superior  laryngeal  artery  upon  the  proximal  side  of  its 
ligature  if  it  has  already  been  divided  and  tied.  The  other  half  of 
the  thyro-hyoid  membrane  is  then  cut  in  a  similar  manner.  If  it 
is  desired  to  excise  the  epiglottis  also,  and  this  is  usually  wise,  a 
probe-pointed  knife  may  be  introduced  through  the  incision  in  the 
thyro-hyoid  membrane,  between  the  upper  border  of  thyroid  cartilage 
and  the  hyoid  bone,  in  a  direction  upward  and  backward;  so  that, 
as  the  cut  is  made,  the  blade  of  the  knife  passes  between  the  base 
of  the  tongue  and  the  epiglottis.  The  finger  in  the  mouth  may 
serve  to  guide  the  knife.  If  the  epiglottis  is  to  be  left,  we  cut  di- 
rectly backward  between  the  upper  border  of  the  thyroid  cartilage 
and  the  hyoid  bone,  thus  leaving  the  epiglottis  attached  to  the  poste- 
rior aspect  of  the  hyoid  bone  and  to  the  root  of  the  tongue.  The 
front  of  the  larynx  is  then  seized  with  a  sharp  hook  or  volsella  forceps 
and  drawn  directly  forward;  so  that  its  posterior  wall,  composed  of 
the  broad  posterior  part  of  the  cricoid  cartilage,  may  be  separated 
from  the  anterior  wall  of  the  pharynx;  the  anterior  wall  of  the 
pharynx  is  very  thin,  consisting  practically  only  of  a  layer  of  mu- 
cous membrane.  If  the  growth  involves  the  anterior  wall  of  the 
pharynx,  this  part  may  be  excised  together  with  the  larynx.  If  the 
pharynx  has  not  yet  become  involved  in  the  disease,  the  separation  of 
the  larynx  from  the  pharynx  will  not  be  found  to  be  difficult  of  accom- 
plishment. 


156  NECK  AND  TONGUE. 

After  the  separation  of  the  larynx  from  the  pharynx  has  been 
completed  to  a  point  below  the  level  of  the  cricoid  cartilage,  the 
larynx  is  cut  away  from  the  trachea,  from  behind  forward,  below 
the  level  of  the  cricoid  cartilage.  In  thus  severing  the  larynx  from 
the  trachea  the  inferior  laryngeal  arteries  and  nerves  are  cut,  and, 
if  the  vessels  have  not  already  been  tied,  they  should  be  secured  as 
they  spurt.    Thus  the  extirpation  is  complete. 

Instead  of  operating  as  described  above,  we  may,  after  freeing 
the  larynx  upon  the  sides,  etc.,  complete  the  operation  by  cutting 
the  larynx  away  from  the  trachea  below  the  level  of  the  cricoid 
cartilage,  packing  the  stump  of  the  trachea  at  once  with  a  pad  to 
prevent  the  entrance  of  the  blood  (a  preliminary  tracheotomy  having 
been  done) ;  and  then,  drawing  the  larynx  forward  with  a  sharp  hook 
or  volsella,  this  is  separated  from  the  anterior  wall  of  the  pharynx 
from  below  upward;  and,  as  the  final  step  of  the  operation,  the 
larynx  is  cut  away  from  its  attachment  to  the  hyoid  bone  by  carry- 
ing the  knife  through  the  thyro-hyoid  membrane. 

The  superior  laryngeal  arteries,  that  enter  the  larynx  upon  the 
sides,  are  best  secured  before  beginning  the  actual  isolation  of  the 
larynx,  but  they  may  be  again  divided  accidentally  during  the  final 
steps  of  the  operation,  and  in  this  case  should  be  again  clamped  and 
tied;  other  vessels  may  be  secured  as  they  are  encountered  during 
the  course  of  the  operation.  The  wound  is  best  left  open  in  part.  If 
the  accessory  lateral  skin  incisions  have  been  made,  and  the  sterno- 
mastoids  have  been  divided,  these  parts  may  be  brought  together 
with  sutures.  The  opening  in  the  pharynx  should  be  closed  as  nearly 
completely  as  possible  with  interrupted  silk  sutures,  their  ends  being 
left  long  to  facilitate  their  removal  later.  It  may  be  possible  in  some 
cases  to  close  off  the  pharyngeal  space  from  the  wound  completely 
by  uniting  the  upper  cut  edge  of  the  pharynx  to  the  tissues  below 
the  hyoid  bone.  This  is  done  with  a  number  of  silk  sutures  placed 
fairly  close  together,  and  is  a  great  advantage,  as  it  diminishes  the 
likelihood  of  infection. 

It  is  necessary  to  arrange  good  drainage  with  the  head  low,  so 
as  to  avoid  the  entrance  of  wound  secretions  into  the  trachea.  It 
is  well  to  leave  the  tampon  cannula  in  the  trachea  for  a  few  days  if 
it  has  been  used  during  the  operation.  The  wound  should  be  prop- 
erly packed  and  the  dressings  changed  at  rather  frequent  intervals. 

After  the  operation  the  patient  is  fed  per  rectum  or  else  through 
a  tube  introduced  into  the  stomach  either  through  the  mouth  or 


OPERATIONS  UPON  THE  NECK.  157 

through  the  wound  in  the  pharynx.  If  a  tracheotomy  has  not  pre- 
ceded the  laryngectomy  by  a  week  or  more,  the  stump  of  the  trachea 
should  he  sutured  to  the  skin  in  order  to  prevent  too  great  retraction 
of  the  trachea.  In  cases  where  the  disease  has  not  spread  beyond 
the  larynx,  the  operation  is  comparatively  easy  and  not  accompanied 
by  much  hemorrhage. 

Before  proceeding  with  the  radical  operation  the  larynx  may 
be  split  in  the  middle  line  for  the  purpose  of  exploration.  It  may 
be  that  in  some  early  cases  the  removal  of  one-half  of  the  larynx 
will  suffice. 

Extirpation  of  Half  of  the  Larynx.  —  This  operation  is  quite 
analogous  to  the  one  described  in  the  preceding  paragraphs,  and  may 
be  practiced  in  those  cases  where  the  disease  is  still  limited  to  one 
side  of  the  larynx. 

The  larynx  is  first  split  in  the  middle  line,  without  injuring  the 
vocal  cords,  and  then,  if  the  condition  found  upon  investigation  war- 
rant, the  operation  of  extirpation  of  one-half  of  the  larynx  may  be 
undertaken. 

The  advantages  of  partial  removal  of  the  larynx  in  appropriate 
cases  are  undoubted.  It  is  a  much  less  difficult  and  dangerous  pro- 
cedure and  there  is  no  greater  likelihood  of  recurrence  after  this  less 
radical  operation  when  the  disease  is  still  confined  to  one  side  of  the 
larynx.  The  voice  may  be  almost  perfectly  retained  and  the  ability  to 
swallow  food  is  quickly  regained. 

Operation  for  Goiter. — This  may  consist  of  partial  extirpation, 
enucleation,  ligation  of  thyroid  arteries,  etc.  The  operation  may  be 
performed  under  local  anaesthesia — Schleich  infiltration  method 
(Kocher,  Eeverdin,  Eoux)  or  a  general  anaesthetic  may  be  used.  If 
a  general  anaesthetic  is  employed  care  must  be  exercised  during  its 
administration,  because  urgent  symptoms  due  to  interference  with  res- 
piration may  arise.  Of  the  general  anaesthetics,  chloroform  is  the 
preferable  one.  The  patient  should  be  placed  in  that  position  which 
causes  the  least  obstruction  to  breathing. 

Operation  is  indicated  as  soon  as  the  tumor  interferes  seriously 
with  respiration  or  shows  inflammatory  changes  or  a  tendency  to 
malignant  degeneration.  Tumors  that  grow  downward  into  the  root 
of  the  neck  or  mediastinum,  causing  pressure  upon  the  trachea, 
should  be  operated  upon  early.  Operation  should  be  undertaken  as 
soon  as  symptoms  of  Basedow^s  disease  begin  to  make  their  appear- 
ance. 


158  NECK  AND  TONGUE. 

Partial  Extikpation  (Kocher). — As  a  rule,  but  one  lobe  is 
extirpated.  If  the  disease  involves  both  lobes,  then  one  entire  lobe, 
the  larger,  should  be  excised  and  the  other  lobe  only  in  part.  At 
least  one-fourth  or  one-fifth  of  the  gland  substance  should  be  left. 
The  entire  organ  should  never  be  extirpated.  Even  if  the  whole 
gland  is  apparently  involved  a  portion,  at  least  one-fourth  or  one- 
fifth,  should  be  permitted  to  remain. 

A  transverse  incision  passing  across  the  front  of  the  neck  from 
the  edge  of  one  sterno-mastoid  muscle  to  the  edge  of  the  other  is 
made.  If  the  tumor  is  situated  low  down,  in  the  root  of  the  neck, 
the  incision  should  be  placed  low,  just  above  the  sternal  notch. 

Instead  of  the  incision  above  described  the  tumor  may  be  ex- 
posed through  a  right  angle  incision  which  commences  upon  the  side 
of  the  neck  behind  the  inner  edge  of  the  sterno-mastoid  muscle  at 
the  level  of  the  thyroid  cartilage;  from  that  point  the  incision  is 
carried  transversely  inwardly  to  the  middle  line  and  then  downward 
as  far  as  the  sternal  notch.  This  incision  is  adapted  to  those  tumors 
that  are  situated  high  up  and  are  of  unusual  size.  The  incision 
penetrates  through  the  skin,  fat,  and  platysma  muscle,  and  exposes 
the  sterno-hyoid  and  sterno-thyroid  muscles,  covered  by  the  deep 
cervical  fascia,  and  the  sterno-mastoid  muscle.  Several  subcutaneous 
venous  branches  are  divided, — the  anterior  jugular  and  communicat- 
ing branch  from  the  external  jugular;  these  should  be  clamped  and 
tied  or  they  may  be  ligated  doubly  before  they  are  severed.  The  ex- 
ternal jugular  is  usually  not  cut. 

The  tumor  mass  may  now  be  seen  bulging  beneath  the  depressor 
muscles  of  the  hyoid  bone  (the  sterno-hyoid  and  sterno-thyroid),  which 
are  usually  found  displaced  more  or  less  toward  that  side  of  the  neck 
which  lodges  the  tumor.  The  tumor  is  exposed  by  cutting  through  the 
deep  cervical  fascia  between  the  edges  of  the  sterno-hyoid  muscles. 
This  incision  in  the  deep  fascia  should  be  sufficiently  liberal.  If  more 
room  is  required  the  fingers  may  be  hooked  under  the  sterno-hyoid 
and  sterno-thyroid  muscles  and  these  may  be  divided  near  the  hyoid 
bone.  It  may  be  necessary  to  extend  the  incision  into  the  anterior 
margin  of  the  sterno-mastoid.  At  this  stage  the  operator  should 
assure  himself  that  he  has  penetrated  completely  through  the  loose 
connective-tissue  envelope  right  down  to  the  true  capsule  of  the 
gland. 

Sweeping  around  in  all  directions  with  the  fingers  close  to  the 
surface  of  the  tumor  mass,  the  effort  is  made  to  separate  it  and  de- 


OPERATIONS  UPON  THE  NECK.  159 

liver  it  partly  through  the  incision.  Connective-tissue  hands  that 
hold  the  tumor  and  resist  its  delivery  and  which  are  usually  vascular 
should  be  hooked  up  with  the  finger  or  ligature  carrier,  clamped  doubly 
and  divided  with  the  scissors.  After  the  tumor  has  been  thus  partly 
detached  it  is  drawn  still  farther  out  of  the  incision  and  the  opera- 
tor is  then  ready  for  the  next  step  of  the  procedure,  the  ligation  of 
the  principal  vessels. 

While  the  mass  is  pulled  downward  and  toward  the  opposite  side 
the  superior  thyroid  vessels  are  sought  near  the  upper  pole  of  the 
tumor;  a  ligature  is  passed  with  the  blunt  carrier,  tied  double,  and 
the  vessels  divided  between  the  ligatures.  The  inferior  thyroid 
artery  is  found  deep  in  the  root  of  the  neck.  It  is  a  branch  of  the 
thyroid  axis;  emerging  from  behind  the  common  carotid  artery,  it 
ascends  upward  and  inward  to  reach  the  lower  part  of  the  gland, 
crossing  the  inferior  recurrent  laryngeal  nerve  in  its  course.  Firm 
traction  must  be  made  upon  the  tumor,  drawing  it  upward  and  over 
toward  the  opposite  side  and  the  skin  and  muscles  well  retracted. 
With  the  fingers  in  the  wound  the  pulsating  vessel  may  be  felt  as  it 
passes  forward  across  the  side  of  the  trachea  to  reach  the  gland. 
About  the  level  of  the  sixth  cervical  vertebra  the  artery  passes  across 
the  front  of  the  recurrent  laryngeal  nerve,  which  ascends  alongside 
the  trachea  to  enter  the  larynx.  The  artery  should  be  carefully  iso- 
lated, taking  pains  to  avoid  injurying  the  nerve  and  a  ligature  passed 
around  it  with  a  blunt  carrier  and  tied.  An  artery  forceps  is  applied 
to  the  vessel  close  to  the  tumor  and  the  artery  then  divided  between 
the  clamp  and  the  ligature.  The  inferior  thyroid  veins  are  tied 
double  and  severed.  An  arteria  thyroidea  ima  is  occasionally  en- 
countered ascending  toward  the  lower  part  of  the  gland;  this  vessel 
and  its  accompanying  veins  should  be  ligated  double  and  divided 
between  the  ligatures. 

There  remains  now  to  make  the  section  through  the  isthmus; 
this  is  detached  and  squeezed  between  the  blades  of  a  heavy  com- 
pression forceps.  The  forceps  is  then  removed  and  the  isthmus 
ligated,  the  ligature  being  placed  so  as  to  secure  the  isthmus  as  the 
site  of  the  groove  made  with  the  compression  forceps.  If  a  third, 
pyramidal,  lobe  is  present,  it  should  also  be  detached  and  removed 
together  with  the  tumor  mass.  The  venous  branches  that  unite  the 
veins  of  the  two  lobes  of  the  gland  across  the  isthmus,  corresponding 
to  its  upper  and  lower  borders,  may  be  clamped  and  ligated  sepa- 
rately. 


160  NECK  AND  TONGUE. 

The  tumor  mass  is  still  attached  to  the  side  of  the  trachea  and 
larynx.  Care  should  he  exercised,  in  separating  it  from  these  struc- 
tures, to  avoid  injuring  the  recurrent  nerve,  which  lies  immediately 
beneath  it  in  the  groove  between  the  trachea  and  oesophagus.  Some 
surgeons  (Kocher  among  them)  advise  cutting  the  main  bulk  of  the 
tumor  mass  away  from  that  part  of  the  capsule  and  gland  which  are 
in  relation  with  the  side  of  the  trachea,  etc.,  these  portions  being 
allowed  to  remain  to  cover  and  protect  the  nerve. 

After  all  hemorrhage  has  been  controlled  the  wound  is  flushed 
out  with  salt  solution.  If  muscles  have  been  divided  their  ends 
should  be  reunited  by  suture.  A  gauze  drain  which  is  allowed  to 
remain  for  twenty-four  hours  is  introduced.  The  edges  of  the  skin 
are  brought  into  accurate  apposition  with  suture  except  the  lower 
part  through  which  the  gauze  drainage  strips  emerge. 

Enucleation. — This  method  of  treatment  is  adapted  to  those 
cases  that  present  isolated  diseased  masses  in  the  midst  of  apparently 
normal  gland  tissue. 

The  incision  and  subsequent  steps  of  this  procedure  until  the 
stage  is  reached  where  the  capsule  of  the  gland  is  exposed  are  the 
same  as  those  described  in  the  preceding  operation.  The  capsule 
is  incised  in  a  situation  where  it  is  fairly  free  from  blood-vessels. 
Vessels  that  are  divided  are  clamped  and  ligated.  Penetrating 
through  the  gland  substance  with  the  finger  the  mass  that  is  to  be 
enucleated  is  shelled  out;  if  any  additional  masses  are  to  be  felt 
these  are  also  enucleated  through  the  same  opening.  If  the  mass 
ruptures  (cystic  goiter)  during  this  step  the  wall  of  the  cyst  should 
be  peeled  out. 

The  cavity  is  packed,  temporarily,  with  strip  gauze  to  check  the 
hemorrhage.  The  packing  is  allowed  to  remain  for  a  few  minutes 
and  then  removed.  If  the  hemorrhage  has  ceased  a  plug  of  strip 
gauze  is  introduced  into  the  cavity  and  the  incision  in  the  capsule 
sutured  except  its  lower  part  where  the  gauze  drain  emerges.  If  the 
temporary  tamponade  fails  to  control  the  hemorrhage  then  the  in- 
cision in  the  capsule  must  be  held  wide  open  with  retractors  and 
individual  bleeding  points  sought  for  and  ligated.  If  the  hemor- 
rhage is  a  profuse  general  oozing  the  packing  may  be  replaced  and 
firm  pressure  applied  with  a  snug  bandage.  Caution  must  be  exer- 
cised in  this  regard  because  pressure  that  is  sufficient  to  control  the 
hemorrhage  under  these  circumstances  may  compress  the  trachea  to 
such  an  extent  as  to  interfere  seriously  with  respiration.     In  order 


OPERATIONS  UPON  THE  NECK.  161 

finally  to  control  the  bleeding  it  may  be  necessary  to  ligate  the  main 
arterial  branches  that  supply  the  gland  or  else  to  extirpate  the  half 
of  the  gland  that  has  been  incised. 

The  incision  in  the  skin  is  closed  by  suture  except  the  part 
below  where  the  drainage  strips  emerge. 

Ligation  op  Thyroid  Arteries. — This  plan  of  treatment  has 
been  employed  in  the  hope  of  bringing  about  a  shrinkage  of  the  goiter, 
but  it  has  failed  to  yield  satisfactory  results.  In  some  few  cases  liga- 
tion of  all  the  arteries  has  been  promptly  followed  by  marked  diminu- 
tion in  the  size  of  the  tumor.  The  superior  and  inferior  thyroid 
arteries  of  both  sides  must  be  ligated. 

External  (Esophagotomy. — This  operation  is  usually  done  for 
the  removal  of  a  foreign  body  impacted  in  the  oesophagus. 

The  patient  lies  upon  the  back,  with  the  shoulders  raised  and 
the  head  thrown  back  and  over  toward  the  right  side. 

A  soft  rubber  tube  is  introduced  into  the  oesophagus  as  far  as 
it  will  go  to  serve  as  a  guide.  The  oesophagus  is  approached  through 
an  incision  in  the  left  side  of  the  neck. 

The  incision  is  made  about  three  inches  long,  corresponding  to 
the  anterior  border  of  the  sterno-mastoid  muscle,  the  midpoint  of 
the  incision  being  upon  a  level  with  the  cricoid  cartilage;  it  is  car- 
ried through  the  skin  and  subcutaneous  fatty  layer,  including  the 
platysma,  and  exposes  the  anterior  edge  of  the  sterno-mastoid  mus- 
cle. The  sterno-mastoid  is  drawn  aside  and  the  underlying  layer  of 
deep  cervical  fascia  is  incised,  when  the  internal  jugular  vein  and 
the  common  carotid  artery,  lying  in  their  connective-tissue  sheath 
and  crossed  by  the  anterior  belly  of  the  omo-hyoid  muscle,  are  ex- 
posed. These  vessels  are  drawn  outward  with  a  blunt  retractor. 
The  lateral  lobe  of  the  thyroid  gland,  partly  covered  by  the  sterno- 
hyoid and  sterno-thyroid  muscles,  is  then  recognized.  These  struc- 
tures are  drawn  toward  the  middle  line  with  a  blunt  retractor.  The 
trachea,  which  may  now  be  readily  felt  with  the  fingers,  is  a  guide 
to  the  oesophagus,  the  oesophagus  being  located  posterior  to  the 
trachea  and  protruding  well  beyond  its  left  border.  The  tube  in  the 
oesophagus  assists  in  locating  it,  and  the  foreign  body,  if  present,  may 
also  be  felt.  The  middle  thyroid  vein,  as  it  passes  outward  from  the 
thyroid  gland  to  enter  the  internal  jugular,  may  be  met  with,  and,  if  it 
is  in  the  way,  may  be  cut  and  tied.  The  inferior  thyroid  vein  may 
also  be  seen. 

The  oesophagus  is  entered  in  the  inferior  carotid  triangle, — i.e., 


162  NECK  AND  TONGUE. 

below  the  omo-hyoid, — and,  if  necessary,  this  muscle  may  be  drawn 
to  one  side  or  divided.  The  recurrent  laryngeal  nerve,  as  it  ascends 
to  enter  the  larynx,  lies  in  front  of  the  oesophagus,  in  the  space 
between  the  trachea  in  front  and  the  oesophagus  behind,  and  should 
be  avoided  in  incising  the  oesophagus.  The  nerve,  during  the. opera- 
tion, is  not  encountered,  and  may  be  avoided  by  making  the  opening 
in  the  oesophagus  well  upon  the  side  and  thus  keeping  away  from 
the  front  of  the  tube. 

The  wall  of  the  oesophagus  is  picked  up  with  two  mouse-toothed 
forceps,  and  an  incision  made  corresponding  to  its  long  axis  and  of 
sufficient  length  to  permit  the  extraction  of  the  foreign  body  or  any 
other  necessary  manipulation. 

In  incising  the  oesophagus  one  should  make  a  clean  cut  in  order 
to  avoid  getting  between  the  layers  of  the  wall  of  the  tube,  which 
ma}'  readily  happen  owing  to  the  looseness  of  the  tissue  between 
its  muscular  and  mucous  coats.  Some  oesophageal  branches  of  the 
inferior  thyroid  may  be  divided  in  making  the  opening  in  the  wall 
of  the  oesophagus  and  these  must  be  clamped  and  ligated. 

The  wound  in  the  wall  of  the  oesophagus  may  be  closed  with 
several  interrupted  sutures  of  silk  or  chromicized  catgut,  but  the 
external  wound  in  the  neck,  leading  down  to  the  incision  in  the 
oesophagus,  should  be  packed  and  left  unsutured. 

If  the  object  of  the  operation  is  to  establish  a  permanent  fistula 
(cesophagostomy),  the  edges  of  the  incision  in  the  oesophagus,  includ- 
ing its  mucous  and  muscular  coats,  may  be  fixed  to  the  edges  of  the 
skin  incision  with  several  interrupted  silk  stitches. 

Ligation  of  Blood-vessels.  The  Common  Carotid  Artery. — 
The  common  carotid  may  be  tied  either  above  or  below  the  point 
where  the  omo-hyoid  crosses  it,  which  is  upon  a  level  with  the  cricoid 
cartilage.  It  is  ligated  preferably  and  more  readily  in  the  so-called 
superior  carotid  triangle:    above  the  crossing  of  the  omo-hyoid. 

The  linear  guide  to  the  common  carotid  is  a  line  drawn  from 
a  point  midway  between  the  angle  of  the  jaw  and  the  mastoid  process 
to  the  sterno-clavicular  articulation.  The  muscular  guide  is  the 
anterior  border  of  the  sterno-mastoid  muscle. 

The  incision  is  made  about  two  inches  long,  corresponding  to 
the  anterior  border  of  the  sterno-mastoid,  its  midpoint  upon  a  level 
with  the  cricoid  cartilage.  This  incision  penetrates  through  the 
skin  and  subcutaneous  fatty  layer,  including  the  platysma,  and 
should   expose   the   anterior   border    of   the   sterno-mastoid    muscle. 


OPERATIONS  UPON  THE  NECK. 


163 


The  edge  of  the  .sterno-mastoid  should  be  recognized  and  drawn 
outward,  and  then,  after  carefully  incising  the  underlying  layer  of 
deep  cervical  fascia, — the  fascia  that  separates  the  vessels  from  the 
sterno-mastoid  muscle, — the  vessels,  surrounded  by  some  loose  con- 
nective tissue,  are  exposed — first,  the  internal  jugular  vein,  big  and 
thin-walled,  lying  to  the  outer  side  of  the  artery,  and  then  the  com- 
mon carotid,  whose  pulsation  is  readily  felt  and  seen  and  which  lies 
to  the  inner  side  of  the  vein.     The  pneumogastric  nerve,  which  is 


./  '  I 


Fig.  81. — A,  incision  for  removal  of  lower  jaw;  B,  incision  for  ligation  of 
lingual  artery  and  Kocher's  amputation  of  tongue;  C,  incision  for  ligation  of 
common  carotid  and  for  cesophagotomy. 


located  between  the  artery  and  vein,  but  behind  them,  is  not  seen. 
The  anterior  belly  of  the  omo-hyoid  is  seen  as  it  crosses  the  vessels 
opposite  the  cricoid  cartilage.  The  loop  formed  by  the  descendens 
and  communicans  noni  may  also  be  recognized  upon  the  front  of 
the  vessels.  The  superior  thyroid  vein  crosses  the  artery  from 
within  outward  above  the  omo-hyoid  muscle,  and  the  middle  thyroid 
vein  below  this  muscle.  If  these  vessels  are  cut,  they  should  be 
clamped  and  tied. 

The  connective-tissue  sheath  which  incloses  the  artery  should 


164  NECK  AND  TONGUE. 

be  picked  up  with  mouse-tooth  forceps,  and  nicked  with  the  point 
of  the  knife  in  the  direction  of  the  long  axis  of  the  vessel;  into 
the  opening  thus  made,  a  director  is  introduced,  and,  working  close 
to  its  wall,  the  vessel  is  separated  all  around,  taking  care  to  avoid 
the  pneumogastric  nerve,  which  lies  posteriorly.  A  blunt-pointed 
aneurism  needle  is  then  introduced  into  the  opening  and  carried 
around  the  artery  from  without  inward,  entering  between  the  artery 
and  the  vein.  The  ligature  is  then  drawn  around  the  vessel,  and 
we  are  ready  to  tie.  The  ligature  should  be  of  ordinary  catgut  and 
tied  with  a  square  knot.  After  the  ligature  is  in  place  and  before 
it  is  tied  the  parts  should  be  again  inspected  in  order  to  make  sure 
that  the  nerve  is  not  included.  Some  surgeons  tie  the  artery  double 
and  divide  it  between  the  ligatures,  but  this  is  probably  unnecessary. 
The  incision  is  closed  with  a  catgut  suture. 

The  External  Carotid. — The  ligation  of  the  external  carotid 
is  practiced  as  a  preliminary  to  many  bloody  operations  about  the 
mouth,  jaws,  etc.,  and  to  control  hemorrhage  from  parts  supplied  by 
its  branches  when  the  branches  themselves  are  not  accessible.  The 
linear  guide  to  the  artery  is  the  same  as  that  for  the  common  carotid; 
the  muscular  guide  is  the  anterior  edge  of  the  sterno-mastoid.  At 
the  upper  border  of  the  thyroid  cartilage  the  common  carotid  artery 
bifurcates  into  the  external  and  internal  carotids,  and  it  is  close  to  its 
origin,  near  the  upper  border  of  the  thyroid  cartilage,  that  the  ex- 
ternal carotid  is  ligated.  The  incision  commences  at  the  level  of  the 
hyoid  bone  and  is  carried  downward,  for  a  distance  of  about  two 
inches,  along  the  anterior  border  of  the  sterno-mastoid.  The  in- 
cision penetrates  through  the  skin,  fat,  and  platysma  muscle  down 
to  the  deep  cervical  fascia,  exposing  the  edge  of  the  sterno-mastoid 
muscle,  which  should  be  recognized.  The  edges  of  the  incision  are 
drawn  apart  with  blunt-pronged  retractors  and  the  deep  cervical 
fascia  is  then  incised. 

The  pulsation  of  the  artery,  within  its  connective-tissue  sheath, 
may  now  be  both  seen  and  felt.  The  external  carotid  artery  lies  a 
little  in  front  of  the  anterior  edge  of  the  sterno-mastoid.  The  in- 
ternal carotid,  together  with  the  internal  jugular  vein  and  pneumo- 
gastric nerve,  lies  posterior  to  the  external  carotid,  beneath  the 
anterior  edge  of  the  sterno-mastoid.  Corresponding  to  the  upper 
border  of  the  thyroid  cartilage,  the  loose  connective  tissue  that  in- 
vests the  artery  is  picked  up  with  a  thumb  forceps  and  snipped  with 
the  point  of  the  knife,  cutting  in  a  direction  corresponding  to  the  long 


OPERATIONS  UPON  THE  NECK.  165 

axis  of  the  vessel;  into  the  opening  which  is  thus  made  a  blunt 
director  is  introduced  and  worked  around  the  vessel,  sticking  close 
to  its  wall.  Through  the  path  thus  made  by  the  director  a  ligature 
is  carried  around  the  vessel  in  the  eye  of  an  aneurism  needle.  The 
ligature  is  then  tied  and  the  incision  closed.  After  the  ligature  has 
been  carried  around  the  artery  it  may  be  left  untied,  with  its  ends 
hanging  out  of  the  incision,  to  be  tied  only  in  case  an  emergency 
arises  calling  for  its  use. 

The  Internal  Carotid. — The  ligation  of  the  internal  carotid 
is  but  seldom  called  for.  The  internal  carotid  may  be  tied  through 
an  incision  similar  to  that  for  ligation  of  the  external  carotid.  The 
vessel  is  found  underneath  the  anterior  edge  of  the  sterno-mastoid, 
which  is  the  muscular  guide  to  it.  The  internal  carotid  has  the 
same  relations  to  the  internal  jugular  vein  and  pneumogastric  nerve 
that  the  common  carotid  has,  the  internal  carotid  being  really  the 
continuation  of  the  common;  and  these  structures  must  be  avoided 
in  isolating  the  vessel  and  passing  the  ligature. 

The  Subclavian  Artery. — The  third  part  of  the  subclavian 
artery  is  tied  after  it  is  exposed  in  the  subclavian  triangle. 

The  patient  is  placed  with  the  shoulders  somewhat  raised  and 
the  head  thrown  back  and  turned  toward  the  opposite  side,  the  arm 
being  drawn  down  to  depress  the  shoulder.  The  incision  corresponds 
to  the  middle  third  of  the  clavicle.  It  is  placed  just  above  the 
clavicle,  and  extends  from  the  anterior  border  of  the  trapezius  for- 
ward and  inward  almost  as  far  as  the  outer  border  of  the  sterno- 
mastoid  muscle;  the  incision  falls  a  little  short  of  the  edge  of  the 
sterno-mastoid  muscle  in  order  to  avoid  the  external  jugular  vein. 
The  incision  in  the  skin  may  be  made  by  drawing  the  integument  of 
the  neck  downward  over  the  surface  of  the  clavicle  and  then  cutting 
through  it,  down  upon  the  surface  of  the  clavicle;  when  the  skin 
is  released,  the  incision  is  found  to  lie  just  above  and  parallel 
with  the  clavicle.  This  incision  reaches  through  the  skin,  fat,  and 
platysma  down  to  the  deep  fascia.  The  deep  fascia,  which  reaches 
from  the  edge  of  the  trapezius  muscle  behind  to  the  sterno-mastoid 
in  front,  is  now  incised,  avoiding  the  external  jugular  vein,  which 
pierces  the  deep  cervical  fascia  behind  the  outer  edge  of  the  sterno- 
mastoid  muscle.  Beneath  the  deep  fascia  the  venous  plexus,  formed 
by  the  transversalis  colli  and  suprascapular,  is  encountered.  These 
veins  may  be  wounded,  but  are  readily  clamped;  often,  however, 
they  can  be  avoided  as  the  knife  may  be  discarded  after  the  deep 


1G6  NECK  AND  TONGUE. 

fascia  has  been  incised.  Beneath  the  deep  fascia  there  is  also  a  con- 
siderable quantity  of  loose  fat  and  connective  and  lymphatic  tissue. 

The  posterior  belly  of  the  omo-hyoid  muscle,  which  lies  pretty 
low  down  near  the  clavicle,  is  now  sought  and  must  be  drawn  upward 
to  show  the  subclavian  triangle,  of  which  it  forms  the  upper  bound- 
ary, the  anterior  boundary  being  formed  by  the  sterno-mastoid  and 
the  inferior  boundary  by  the  clavicle. 

Within  the  triangle,  passing  transversely  outward,  are  the  trans- 
versalis  colli  and  suprascapular  arteries.  These  vessels  should  be 
avoided.  The  tendon  of  the  scalenus  anticus,  which  is  the  guide  to 
the  subclavian  artery,  may  be  felt  as  a  tense  cord  passing  straight 
up  and  down  beneath  the  posterior  or  outer  border  of  the  sterno- 
mastoid  and  attached  below  to  the  first  rib.  If  this  tendon  is  fol- 
lowed downward  as  far  as  its  attachment  to  the  first  rib,  one  may 
locate  the  subclavian  artery  as  it  passes  outward  and  forward  from 
behind  the  tendon  of  the  scalenus  anticus  muscle,  resting  directly 
upon  the  upper  surface  of  the  first  rib.  That  part  of  the  subclavian 
artery  which  lies  upon  the  first  rib  is  the  part  which  is  ligated.  The 
subclavian  vein  lies  a  considerable  distance  to  the  inner  side  of  and 
anterior  to  the  artery,  the  tendon  of  the  scalenus  anticus  interven- 
ing between  them,  and  is  not  apt  to  be  encountered  during  the  op- 
eration. Within  the  triangle,  above  the  subclavian  artery,  may  be 
seen  the  three  cords  of  the  brachial  plexus.  These  pass  obliquely 
downward  and  outward  from  behind  the  scalenus  anticus  muscle,  and 
should  not  be  mistaken  for  the  artery,  which  is  the  lowest  structure 
in  this  triangle  and  rests  directly  upon  the  upper  surface  of  the  first 
rib.  These  structures  may  all  be  exposed  by  blunt  dissection,  sepa- 
rating with  the  finger  or  handle  of  the  knife,  after  the  deep  fascia 
has  been  incised. 

With  blunt  retractors  the  wound  is  held  open  and  the  con- 
nective-tissue sheath,  which  envelops  the  artery,  picked  up  and 
snipped  with  the  scissors  and  the  artery  then  separated  from  the 
adjoining  structures  with  a  blunt  director,  working  around  the  artery 
close  to  its  wall.  The  aneurism  needle  is  passed  around  the  artery 
from  without  inward,  avoiding  the  cords  of  the  brachial  plexus.  The 
subclavian  vein,  which  lies  below  and  internal  to  the  artery,  is  not 
apt  to  be  in  the  way. 

It  should  also  be  remembered  that  the  dome  of  the  pleura 
reaches  above  the  clavicle  into  the  subclavian  triangle,  and  that 
the  subclavian  artery  (second  part),  as  it  lies  behind  the  tendon  of 


OPERATIONS  UPON  THE  NECK.  167 

the  scalenus  anticus,  rests  upon  the  pleura,  and  care  should  be  taken 
to  avoid  injuring  this  structure,  especially  in  making  way  for  the 
passage  of  the  ligature. 

The  ligature  is  tied  with  a  square  knot,  deep  in  the  wound, 
without  lifting  the  artery  too  much  out  of  its  bed. 

The  Lingual  Artery. — -This  operation  is  usually  performed 
in  combination  with  Kocher's  amputation  of  the  tongue.  The 
lingual  is  a  vessel  of  considerable  size,  that  of  each  side  supplying 
the  corresponding  half  of  the  tongue.  In  order  to  prevent  the 
entrance  of  blood  into  the  larynx  during  the  amputation  of  the 
tongue,  the  patient  is  placed  in  the  Eose  position,  or,  if  a  preliminary 
tracheotomy  has  been  done  and  a  Trendelenburg  tampon  cannula 
introduced,  or  if  an  ordinary  tracheotomy  tube  has  been  introduced 
and  the  pharynx  tamponed,  one  may  operate  with  the  patient  in  the 
ordinary  position,  the  shoulders  somewhat  raised,  and  the  head 
thrown  back  and  over  toward  the  opposite  side. 

An  incision  is  made  which  corresponds  to  the  boundaries  of  the 
submaxillary  triangle.  It  commences  in  front,  at  the  symphysis 
mentis,  and  is  carried  down  to  the  hyoid  bone,  thence  backward 
above  and  parallel  with  the  greater  horn  of  the  hyoid  bone  and  then 
in  a  direction  upward  and  backward  toward  the  mastoid  process  as 
far  as  the  angle  of  the  lower  jaw  (see  Fig.  81). 

This  incision  penetrates  through  the  skin,  fat,  and  platysma, 
down  to  the  deep  fascia.  The  apex  of  the  flap,  which  is  thus  marked 
out,  is  seized  with  the  fingers  and  reflected  upward  upon  the  side 
of  the  face  as  far  as  the  lower  border  of  the  jaw-bone.  In  reflecting 
this  flap  we  may,  toward  the  back,  cut  the  external  jugular  vein, 
and  this  should  be  clamped  and  tied.  The  deep  fascia  is  then  incised 
and  the  submaxillary  gland  exposed.  This  gland,  which  is  lodged 
in  a  bed  of  loose  connective  tissue,  is  seized  with  toothed  forceps 
and  enucleated,  together  with  the  adjoining  lymphatic  nodes.  This 
is  accomplished  by  cutting  with  the  knife  close  to  the  gland  or  by 
blunt  dissection  with  the  handle  of  the  knife  or  with  the  finger, 
the  gland  being  finally  cut  away  from  its  duct,  which  disappears 
anteriorly  beneath  the  posterior  border  of  the  mylo-hyoid  muscle  on 
its  way  to  open  into  the  anterior  part  of  the  floor  of  the  mouth. 
The  facial  artery,  if  not  previously  cut,  is  usually  divided  in  enucleat- 
ing this  gland,  and  should  be  tied  when  cut,  or,  still  better,  it  may 
be  tied,  before  it  is  cut,  close  to  its  origin  and  before  it  reaches  the 
submaxillary  gland. 


168  NECK  AND  TONGUE. 

The  facial  vein  is  also  usually  divided  during  this  part  of  the 
operation ;  this  vessel  bleeds  freely,  but  may  be  clamped  and  ligated. 
After  the  submaxillary  gland  has  been  removed,  the  boundaries  of 
the  submaxillary  triangle  axe  readily  made  out;  above,  the  lower 
border  of  the  jaw,  and,  below,  in  front,  and  behind,  the  anterior  and 
posterior  bellies  of  the  digastric  muscle.  The  floor  of  the  submaxil- 
lary triangle  is  formed  in  front  by  the  oblique  fibers  of  the  mylo- 
hyoid and  behind  by  the  perpendicular  fibers  of  the  hyo-glossus, 
which  muscle  lies  on  a  deeper  plane  than  the  mylo-hyoid,  being 
partly  overlapped  by  the  posterior  margin  of  the  latter.  Passing 
from  behind,  horizontally  forward,  above  and  parallel  with  the  hyoid 
bone  and  lying  directly  upon  the  hyo-glossus  muscle  is  the  hypo- 
glossal nerve;  this  never  disappears  anteriorly  beneath  the  poste- 
rior edge  of  the  mylo-hyoid  muscle.  This  nerve  marks  the  upper 
boundary  of  the  lingual  triangle,  which  is  really  the  apex  of  the 
submaxillary  triangle.  The  base  of  the  lingual  triangle  is  formed 
by  the  hypoglossal  nerve,  and  its  lower  borders,  in  front  and  behind, 
by  the  anterior  and  posterior  bellies  of  the  digastric.  The  floor  of 
the  lingual  triangle  is  formed  by  the  hyo-glossus,  and  beneath  this 
muscle  the  lingual  artery,  accompanied  by  a  vein,  is  located ;  so  that, 
if  this  muscle  is  picked  up  with  tooth  forceps  and  snipped  through 
with  the  knife  or  scissors,  the  lingual  artery  is  readily  found  and 
may  be  hooked  up  with  an  aneurism  needle  and  tied.  Locating 
and  tying  the  lingual  artery  in  this  triangle  is  very  simple.  We  are 
then  ready  to  proceed  with  the  amputation  of  the  tongue. 

Should  it  be  desirable  to  tie  the  lingual  artery  without  remov- 
ing the  submaxillary  gland,  one  may,  after  cutting  through  the  deep 
fascia,  draw  the  gland  up  out  of  the  way  and  then  proceed  as  above. 
In  this  case  it  will  not  be  necessary  to  make  such  an  extensive  incision 
in  the  skin. 

The  Inferior  Thyroid  Artery.  —  This  vessel  is  occasionally 
ligated  on  both  sides,  together  with  both  superior  thyroid  arteries,  as 
a  palliative  measure  for  the  purpose  of  diminishing  the  blood-supply 
in  cases  of  goiter.  This  artery  is  the  largest  branch  of  the  thyroid 
axis.  It  ascends  deep  in  the  root  of  the  neck  and  opposite  the  promi- 
nent anterior  tubercle  of  the  sixth  cervical  vertebra,  the  tubercle  of 
Chassaignac,  passes  inward  behind  the  common  carotid  artery,  etc., 
to  reach  the  lower  part  of  the  lateral  lobe  of  the  thyroid  gland.  It  is 
crossed  by  the  sympathetic  nerve,  the  middle  cervical  ganglion  resting 
upon  the  artery  either  anterior  or  posterior  to   it.     The  recurrent 


CERVICAL  SYMPATHETIC.  169 

larj-ngeal  nerve'  as  it  ascends  in  the  root  of  the  neck  also  crosses  the 
artery. 

An  incision  about  three  inches  in  length  is  made  along  the  ante- 
rior border  of  the  sterno-mastoid  reaching  downward  as  far  as  the 
clavicle.  The  incision  extends  through  the  skin  and  fat  down  to  the 
deep  cervical  fascia.  This  layer  is  divided  in  front  of  the  sterno-mas- 
toid and  the  common  carotid  artery  and  adjacent  structures,  internal 
jugular  vein,  pneumogastric  nerve,  drawn  outward  with  a  blunt  hook. 
With  the  finger  in  the  wound,  the  tubercle  on  the  transverse  process 
of  the  sixth  cervical  vertebra  is  sought.  This  is  the  guide  to  the  artery. 
At  this  level  the  vessel  passes  inward  to  reach  the  lateral  lobe  of  the 
thyroid  gland.  A  ligature  is  carried  around  the  vessel  with  an  aneur- 
ism needle  and  securely  tied.  The  ligature  should  be  applied  to  the 
vessel  some  little  distance  away  from  the  thyroid  gland  so  as  to  avoid 
the  inferior  recurrent  laryngeal  nerve  which  passes  across  the  artery 
as  it  ascends  in  the  neck. 

CERVICAL  SYMPATHETIC. 

Surgical  Anatomy. — The  cervical  sympathetic  is  found  deep  in 
the  neck  behind  the  carotid  artery,  internal  jugular  vein,  and  vagus 
nerve,  resting  upon  the  prevertebral  muscles — the  rectus  capitis 
anticus  major  above  and  the  longus  colli  below.  The  nerve  lies  in 
intimate  contact  with  these  muscles  beneath  the  fascia  that  covers 
them, — the  fascia  prasvertebralis.  At  the  root  of  the  neck  the  nerve 
descends  into  the  thorax. 

The  cervical  portion  of  the  sympathetic  is  marked  by  three 
swellings  or  ganglia, — the  superior,  middle,  and  inferior. 

The  superior  ganglion,  the  largest,  is  fusiform  in  shape  and  about 
one  inch  in  length.  It  is  found  resting  upon  the  rectus  capitis  major 
muscle  opposite  the  second  and  third  vertebrae,  behind  the  internal 
carotid  artery  and  to  the  inner  side  of  the  vagus  nerve.  Among 
other  branches  it  gives  off  the  superior  cardiac  nerve. 

The  middle  cervical  ganglion  is  much  the  smallest  of  the  three. 
It  is  sometimes  absent  or  it  may  be  double.  It  is  situated  at  the 
point  where  the  sympathetic  nerve  crosses  the  inferior  thyroid  ar- 
tery, opposite  the  prominent  tubercle  on  the  transverse  process  of 
the  sixth  vertebra, — the  tubercle  of  Chassaignac.  This  ganglion 
gives  off  thyroid  branches  that  accompany  the  inferior  thyroid  artery 
to  the  thyroid  gland.  The  middle  cardiac  nerve  is  derived  from 
the  middle  ganglion. 


170  NECK  AND  TONGUE. 

The  inferior  cervical  ganglion  is  larger  than  the  middle.  It  is 
irregular  in  shape  and  is  frequently  merged  with  the  first  thoracic 
ganglion.  It  is  situated  opposite  the  neck  of  the  first  rib,  between 
the  scalenus  anticus  and  longus  colli  muscles  and  under  cover  of  the 
vertebral  vessels.  A  branch  from  the  inferior  cervical  ganglion 
curves  around  the  subclavian  artery  and  ascends  to  communicate 
with  the  middle  cervical  ganglion;  it  is  called  the  ansa  Vieussenii. 
The  inferior  ganglion  gives  off  the  inferior  cardiac  nerve. 

Pupillo-dilator  fibers  are  derived  from  the  superior  ganglion 
through  branches  to  the  Gasserian  ganglion  and  thence  through  the 
ophthalmic  division  of  the  fifth  and  the  long  ciliary  nerves. 

Branches  from  the  middle  ganglion  are  distributed  to  the  thy- 
roid glands. 

Accelerator  fibers  to  the  heart  are  divided  from  all  three  gan- 
glia and  from  the  first  thoracic  ganglion. 

Resection  of  Cervical  Sympathetic  (Jonnesco). — Total  bilateral 
resection  of  the  cervical  sympathetic  including  the  three  cervical 
ganglia  and  the  first  thoracic  ganglion.  The  operation  is  done  for 
the  cure  of  exophthalmic  goiter  (Basedow's  disease).  An  interval 
of  about  two  weeks  should  elapse  between  the  first  operation  for 
extirpation  of  the  nerve  on  the  one  side  and  the  second  operation 
for  extirpation  of  the  nerve  on  the  other  side. 

Two  incisions  are  made, — one  in  the  upper  part  of  the  neck  in 
order  to  reach  the  superior  ganglion,  and  one  on  the  lower  part  of 
the  neck  to  gain  access  to  the  middle  and  inferior  ganglia,  etc. 

The  upper  incision  commences  at  the  posterior  border  of  the 
mastoid  process,  and  is  carried  downward  along  the  posterior  border 
of  the  sterno-mastoid  for  a  distance  of  from  3  to  5  cm.  After  pene- 
trating between  the  fibers  of  the  sterno-mastoid  muscle,  the  layer  of 
deep  cervical  fascia  that  lines  its  under  surface  is  incised.  The 
finger  is  then  introduced  into  the  wound  and  the  sterno-mastoid  is 
separated  bluntly  from  prevertebral  muscles  that  lie  beneath  it. 
This  separation  is  not  difficult,  the  finger  working  in  the  natural 
connective-tissue  space  that  exists  between  the  fascia  that  lines  the 
deep  surface  of  the  sterno-mastoid  and  that  which  covers  the  pre- 
vertebral muscles,  the  fascia  praevertebralis.  With  the  finger  this 
separation  is  carried  as  far  upward  as  the  base  of  the  skull  and  as 
far  downward  toward  the  root  of  the  neck,  as  the  finger  can  reach. 
With  a  blunt  retractor  the  sterno-mastoid,  together  with  the  internal 
jugular  vein,  internal  carotid  artery,  and  vagus  nerve,  is  drawn  well 


CERVICAL  SYMPATHETIC.  171 

forward  and  the  sympathetic  nerve  sought.  The  nerve  is  found  lying 
upon  the  prevertebral  muscles,  to  the  inner  side  of  the  anterior  tu- 
bercles of  the  transverse  processes  and  underneath  the  fascia  prsever- 
tebralis.  When  this  layer  of  fascia  is  snipped  through  the  nerve 
comes  into  view,  and  is  readily  identified  by  the  thickened  portion 
that  represents  the  superior  ganglion. 

The  lower  end  of  the  ganglion  is  grasped  with  an  artery  forceps 
and  the  trunk  of  the  nerve  followed  upward  as  far  as  the  base  of  the 
skull.  All  the  branches  that  it  gives  off  are  cut  with  the  scissors  and 
the  nerve  then  seized  as  high  as  possible  above  the  ganglion  and 
with  gradually  increasing  traction  it  is  torn  away.  The  end  of  the 
nerve  with  the  forceps  still  attached  is  brought  out  through  the  in- 
cision.    The  wound  is  temporarily  packed  with  gauze. 

A  second  incision  is  made  in  the  lower  part  of  the  neck.  It 
commences  just  above  the  clavicle  and  extends  upward,  correspond- 
ing to  the  posterior  border  of  the  sterno-mastoid  for  about  4  cm. 
The  posterior  edge  of  the  sterno-mastoid  is  exposed  and  then,  after 
incising  the  underlying  layer  of  deep  cervical  fascia,  the  finger  is 
introduced  into  the  wound.  The  finger  enters  the  lower  part  of  the 
same  connective-tissue  space  that  was  already  explored  with  the 
finger  through  the  upper  incision.  The  finger  is  pushed  downward 
in  the  space  as  far  as  the  clavicle  or  first  rib.  A  blunt  retractor  is 
then  introduced  and  the  edge  of  the  sterno-mastoid — together  with 
the  bundle  of  structures  consisting  of  the  internal  jugular  vein, 
carotid  artery,  vagus  nerve,  etc. — is  drawn  toward  the  middle  line 
and  the  wound  thus  opened  wide.  The  inferior  thyroid  artery  is 
sought.  It  crosses  the  root  of  the  neck  upon  a  level  with  the  promi- 
nent anterior  tubercle  of  the  transverse  process  of  the  sixth  vertebra, 
— the  tubercle  of  Chassaignac.  The  middle  cervical  ganglion  is 
found  usually  behind,  though  sometimes  in  front  of  the  inferior 
thyroid  artery.  At  times  the  ganglion  is  absent  and  represented  by 
a  plexus  that  surrounds  the  inferior  thyroid  artery;  or  this  plexus 
may  be  absent,  the  trunk  of  the  nerve  passing  down  across  the  artery 
without  any  interruption.  Traction  may  be  made  upon  the  nerve 
in  the  upper  and  lower  incisions  in  order  to  positively  identify  it. 

With  the  director  the  nerve  is  separated  and  raised  from  its 
bed,  working  simultaneously  through  both  the  upper  and  lower  in- 
cisions, and  is  then  drawn  down  and  out  through  the  lower  incision. 
The  detachment  of  the  nerve  where  it  crosses  the  inferior  thyroid 
artery  is  easier  when  it  descends  in  front  of  the  vessel.     As  a  rule, 


172  NECK  AND  TONGUE. 

the  nerve  descends  behind  the  artery.  The  branches  that  are  dis- 
tributed from  the  ganglion  to  the  artery  must  be  divided;  also  the 
median  cardiac  nerve  which  may  be  identified  by  its  course  inward, 
and  the  anterior  branch  of  the  ansa  Vieussenii.  The  trunk  is  then 
drawn  down  under  the  artery. 

Following  the  course  of  the  nerve  downward  the  inferior  gan- 
glion is  reached.  This  ganglion  is  situated  behind  the  clavicle,  rest- 
ing upon  the  neck  of  the  first  rib,  between  the  scalenus  anticus  and 
longus  colli  muscles,  partly  covered  by  the  vertebral  vein  and  artery. 
The  nerve  is  seized  with  the  forceps  near  the  ganglion  and  drawn  a 
little  upward  and  the  vertebral  vein  which  covers  the  ganglion  ex- 
posed and  drawn  outward  with  a  blunt  hook;  likewise  the  vertebral 
artery.  There  is  then  exposed  to  view  the  inferior  ganglion  with 
its  many  small  branches,  including  the  nervus  cardiacus  inferior 
and  nervus  vertebralis.  These  branches  are  all  divided  with  the 
scissors.  The  further  separation  of  the  ganglion  is  made  with  the 
fingers  working  downward  past  the  first  thoracic  ganglion,  which  is 
also  detached.  As  the  final  step  of  the  operation  the  first  thoracic 
ganglion  is  seized  with  the  forceps  and  with  gradually  increasing 
traction  is  torn  out.  The  entire  cervical  sympathetic,  including  its 
three  ganglia,  and  the  first  thoracic  ganglion  are  thus  extirpated. 
The  incisions  are  closed  with  suture  without  drainage. 

The  most  difficult  part  of  the  operation  is  the  separation,  etc., 
of  the  inferior  cervical  ganglion.  The  subclavian  artery  lies  at  a 
deeper  level  and  is  not  usually  encountered.  The  phrenic  nerve  lies 
to  the  outer  side,  crossing  the  scalenus  anticus  obliquely  from  above 
downward. 

The  plan  of  operating  through  two  short  incisions  avoids  division 
of  the  superficial  branches  of  the  cervical  flexus,  the  spinal  accessory 
nerve,  and  the  external  jugular  vein. 

OPERATIONS  UPON  THE  TONGUE. 

Amputation  of  the  Tongue  (Kocher),  with  Preliminary  Ligation 
of  the  Lingual  Artery. — Amputation  of  the  tongue  according  to  the 
method  of  Kocher  has  many  advantages :  the  hemorrhage  is  easily 
controlled,  diseased  glands  are  readily  removed,  and  the  incision  is 
well  placed  for  drainage. 

The  position  of  the  patient,  etc.,  has  been  described  in  connec- 
tion with  the  ligation  of  the  lingual  artery. 


OPERATIONS  UPON  THE  TONGUE.  173 

An  incision,  as  described  above  for  the  ligation  of  the  lingual 
artery,  is  made  upon  the  side  of  the  neck,  laying  bare  the  boundaries 
of  the  submaxillary  triangle.  The  lymphatic  nodes  and  submaxillary 
gland  are  then  excised  and  the  lingual  artery  sought  for  and  tied; 
it  is  not  necessary  to  ligate  the  lingual  of  each  side,  yet  this  may  be 
done  with  advantage,  especially  if  the  lymphatics  of  both  sides  are 
involved,  as  they  can  then  be  extirpated  at  the  same  time  that  the 
vessel  is  ligated. 

After  having  excised  the  submaxillary  lymphatic  nodes  and 
gland  and  tied  the  lingual  artery  and  secured  all  bleeding  points, 
an  incision  is  made  with  the  knife  through  the  floor  of  the  sub- 
maxillary triangle, — i.e.,  through  the  mylo-hyoid  muscle  and  the 
mucous  membrane  of  the  mouth, — close  to  the  inner  surface  of  the 
body  of  the  lower  jaw.  This  opening  may  be  farther  enlarged  with 
the  scissors  or  fingers.  The  tip  of  the  tongue  is  then  seized  with  a 
forceps  and  drawn  out  into  the  wound  in  the  neck,  through  the 
opening  in  the  floor  of  the  mouth,  and  making  considerable  traction, 
first  to  one  side  and  then  to  the  other,  the  tongue  is  separated  from 
its  attachment  to  the  floor  of  the  mouth,  as  far  back  toward  the  base 
as  possible.  This  is  done  with  the  blunt-pointed  curved  scissors, 
snipping  through  the  septum  of  the  tongue  and  working  close  to  its 
under  surface.  During  this  step  of  the  operation,  and  while  traction 
is  being  made  upon  the  tongue,  one  should  examine  occasionally  with 
the  finger  for  bands,  etc.,  which  tend  to  bind  the  tongue  within  the 
mouth.  The  anterior  pillars  of  the  fauces,  which  are  attached  to  the 
sides  of  the  tongue,  near  its  base,  should  be  cut  close  to  the  surface 
of  the  tongue,  and  then  it  will  be  observed  that  the  organ  can  be 
drawn  out  of  the  mouth  for  a  considerable  distance,  when  it  may  be 
amputated  quite  close  to  its  root.    This  is  done  with  the  scissors. 

The  half  of  the  tongue,  corresponding  to  the  side  upon  which 
the  lingual  has  been  tied,  may  be  cut  through  without  occasioning 
any  bleeding;  but,  if  the  lingual  artery  of  the  other  side  has  not 
been  previously  tied,  the  hemorrhage,  when  this  second  half  of  the 
tongue  is  cut  through,  may  be  embarrassing,  as  there  may  be  some 
difficulty  in  catching  the  cut  end  of  the  artery.  This,  however,  may 
be  provided  against  by  seizing  the  base  of  the  tongue  with  a  toothed 
clamp  behind  the  point  where  it  is  intended  to  amputate  it  before 
cutting  through;  so  that,  when  we  divide  this  half  of  the  tongue, 
we  may  pull  the  stump  forward,  and  seize  the  divided  vessel,  when 
it  spurts,  with  an  artery  clamp. 


174  NECK  AND  TONGUE. 

The  wound  in  the  side  of  the  neck  may  be  closed  with  inter- 
rupted silk-worm  gut  sutures,  except  its  posterior  part,  which  is  left 
open  and  packed  to  carry  off  the  secretions,  etc.,  from  the  mouth. 
The  packing  should  be  introduced  well  into  the  cavity  of  the  mouth. 
The  patient  is  fed  through  a  stomach  tube,  which  is  passed  through 
the  mouth  or  through  the  nose.  This  tube  may  be  passed  before  the 
patient  recovers  from  the  anaesthetic. 

Amputation  of  the  Tongue  (Regnoli-Billroth) . — This  method 
is  applicable  to  those  cases  where  the  floor  of  the  mouth  is  consid- 
erably involved  in  the  disease. 

The  patient  is  placed  in  the  Eose  position,  or  if  a  preliminary 
tracheotomy  has  been  done  and  a  Trendelenburg  tampon  cannula 
introduced  into  the  trachea,  or  if  an  ordinary  tracheotomy  tube  has 
been  introduced  and  the  pharynx  has  been  tamponed,  the  patient 
may  lie  in  the  usual  position  with  the  shoulders  raised  and  the  head 
thrown  back. 

An  incision  is  made  along  the  lower  border  of  the  body  of  the 
jaw  about  6  cm.  long,  the  midpoint  of  the  incision  corresponding  to 
the  symphysis  mentis.  This  incision  penetrates  through  all  the  soft 
parts  down  to  the  bone  and  extends  backward,  upon  either  side, 
nearly  as  far  as  the  anterior  edge  of  the  masseter  muscle.  In  making 
this  incision,  the  facial  artery,  as  it  turns  up  over  the  lower  border 
of  the  jaw-bone,  just  in  front  of  the  masseter,  may  be  avoided. 

From  either  end  of  this  incision  additional  ones  are  made  which 
reach  straight  downward  as  far  as  the  hyoid  bone,  passing  through 
the  integument  and  the  platysma.  Through  the  lateral  incisions, 
on  either  side,  the  lingual  artery  may  be  sought  and  tied,  at  the 
same  time  extirpating  any  diseased  glands,  etc. 

The  cavity  of  the  mouth  is  now  entered  by  severing  the  muscles 
attached  to  the  inner  surface  of  the  body  of  the  lower  jaw  with  a 
knife.  They  should  be  cut  fairly  close  to  the  bone,  and  the  point 
of  the  knife  may  be  guided  with  the  finger  in  the  mouth.  Those 
muscles  that  are  attached  to  the  inner  aspect  of  the  symphysis 
in  the  middle  line  are  divided  first.  A  suture  should  be  passed 
through  the  tip  of  the  tongue  or  it  may  be  seized  with  a  toothed 
clamp  in  order  to  exercise  traction  and  prevent  its  falling  back  into 
the  pharynx  and  obstructing  the  breathing  during  the  course  of  the 
operation. 

After  a  sufficiently  large  opening  has  been  made  in  the  floor 
of  the  mouth,  the  tongue  is  drawn  through  the  wound,  under  the 


OPERATIONS  UPON  THE  TONGUE.  175 

jaw,  and  may  then  be  removed  together  with  the  floor  of  the  mouth 
as  far  back  as  the  epiglottis. 

If  the  lingual  arteries  have  not  been  previously  ligated,  the  base 
of  the  tongue  should  be  seized  with  a  vulsella  forceps  before  it  is 
amputated,  in  order  to  facilitate  the  clamping  of  these  vessels  in  the 
stump  of  the  tongue. 

The  flap  of  skin  and  soft  parts  is  replaced  and  the  wound  closed 
except  posteriorly,  on  one  or  both  sides,  where  the  incision  is  left 
open  and  packed  in  order  to  drain  the  cavity  of  the  mouth. 

Extirpation  of  the  Tongue  through  the  Floor  of  the  Mouth,  with 
Division  of  the  Lower  Jaw. — The  operation  is  preceded  by  a  trache- 
otomy and  the  introduction  of  a  Trendelenburg  tampon  cannula, 
or  an  ordinary  tracheotomy  tube  may  be  used  and  the  pharynx  tam- 
poned. A  soft  rubber  tube  for  feeding  purposes  may  be  passed  into 
the  stomach,  before  the  patient  recovers  from  the  anaesthetic,  either 
through  the  mouth  or  the  nose. 

Sedillot's  Method,  with  Division  of  the  Lower  Jaw  in  the 
Middle  Line. — The  first  incisor  tooth  of  the  lower  jaw  is  extracted. 
An  incision  is  made,  as  in  the  Eegnoli-Billroth  operation,  along  the 
lower  border  of  the  jaw  and  reaching  as  far  as  the  masseter  on  either 
side.  The  lower  lip  is  then  split  in  the  middle  line,  the  incision  being 
carried  down  to  the  bone  through  the  gum  and  periosteum.  The 
lower  jaw  is  then  sawn  through  with  a  metacarpal  or  a  chain  or  a 
Gigli  saw,  and  the  muscles  and  the  mucous  membrane  composing  the 
floor  of  the  mouth  incised  close  to  the  inner  surface  of  the  body  of 
the  lower  jaw-bone. 

Each  half  of  the  jaw  is  now  drawn  well  outward,  away  from  the 
middle  line,  thus  giving  very  free  access  to  the  tongue  and  to  the 
floor  of  the  mouth.  The  tongue  and  that  part  of  the  floor  of  the* 
mouth  which  is  involved  in  the  disease  may  then  be  extirpated. 

If  the  Unguals  have  not  been  previously  tied,  they  may  be 
clamped  after  the  tongue  has  been  amputated,  drawing  the  stump 
of  the  tongue  forward  with  a  vulsella  in  order  to  facilitate  this. 

The  tonsils  and  the  pillars  of  the  fauces  may  also  be  reached 
in  this  operation,  and,  if  the  lower  jaw-bone  is  involved,  it  can  be 
resected  in  part.  Diseased  lymphatic  glands  in  the  neck  may  also 
be  excised  through  this  incision,  which  may  be  made  as  extensive 
as  necessary. 

One  should  attempt  to  bring  the  raw  surfaces  in  the  mouth 
together,  at  least  in  part,  with  interrupted  chromicized  catgut  or 


176  NECK  AND  TONGUE. 

silk  sutures,  their  ends  being  left  long  to  facilitate  their  removal 
later. 

The  two  halves  of  the  jaw  are  brought  together  and  carefully 
wired,  and  the  incision  closed  except  at  its  posterior  part  on  one  or 
both  sides,  where  it  is  left  open  for  packing  and  drainage. 

Langenbeck's  Method,  with  Division  of  the  Lower  Jaw 
on-  one  Side. — Upon  the  side  corresponding  to  the  disease  an  in- 
cision is  carried  from  the  corner  of  the  mouth  through  the  lower 
lip  as  far  as  the  lower  border  of  the  jaw,  whence  it  is  continued 
downward  through  the  integument  of  the  neck  as  far  as  the  side 
of  the  hyoid  bone.  The  upper  part  of  this  incision  splits  the  lip 
and  gum,  passing  through  the  periosteum  down  to  the  bone;  the 
lower  part  of  the  incision  passes  through  the  skin,  fat,  and  platysma. 
All  bleeding  points  are  clamped. 

Through  the  lower  part  of  the  incision,  after  cutting  through 
the  deep  fascia,  the  submaxillary  gland  and  the  neighboring  dis- 
eased lymphatic  nodes  of  this  side  may  be  removed,  and  the  lingual 
artery  tied  as  it  lies  in  the  lingual  triangle,  above  the  hyoid  bone 
and  beneath  the  hyo-glossus  muscle. 

The  canine  tooth  of  the  lower  jaw  is  now  extracted  and  an  open- 
ing made  in  the  floor  of  the  mouth  so  as  to  allow  the  use  of  the  chain 
or  wire  saw  with  which  the  jaw-bone  is  divided.  The  section  through 
the  jaw  should  be,  not  straight  up  and  down,  but  obliquely  from 
above  downward  and  inward  toward  the  symphysis,  so  that  the  tend- 
ency to  dislocation  caused  by  the  pull  of  the  masseter  muscle  may 
thus  be  counteracted.  The  jaw-bone  may  be  divided  with  a  narrow, 
flat  saw  or  with  a  chain  or  wire  saw. 

The  segments  of  the  divided  jaw-bone,  especially  the  shorter 
piece,  are  now  drawn  well  apart  with  sharp  retractors,  and  the  soft 
parts,  muscles  and  mucous  membrane,  which  form  the  floor  of  the 
mouth,  separated  from  their  attachment  to  the  inner  surface  of  the 
bone,  as  far  back,  if  need  be,  as  the  anterior  pillars  of  the  fauces. 
The  tongue  is  then  seized  with  the  toothed  forceps  and  drawn  well 
forward  and  over  toward  the  well  side  and  removed.  One  may  ex- 
cise the  floor  of  the  mouth,  the  pillars  of  the  fauces,  and  the  tonsils, 
if  they  are  diseased,  and  also  resect  a  part  of  the  jaw-bone  if  this 
is  involved. 

If  the  Unguals  have  not  been  previously  ligated,  we  may  clamp 
them  in  the  stump  after  the  tongue  has  been  amputated.  The  seg- 
ments of  the  jaw-bone  are  brought  into  apposition  and  wired,  and 


OPERATIONS  UPON  THE  TONGUE.  177 

the  wound  in  the  soft  parts,  except  its  lower  part,  which  is  left  open 
and  packed  to  carry  off  the  secretions  from  the  mouth,  is  closed  with 
interrupted  silk-worm  gut  sutures. 

One  should  try  to  diminish  the  raw  surface  left  in  the  buccal 
cavity  as  much  as  possible  by  drawing  the  parts  together  with  sepa- 
rate chromicized  catgut  sutures. 

Billeoth's  Method,  with  Bilateeal  Division  of  the  Lowee 
Jaw. — This  is  probably  not  so  satisfactory  as  the  preceding  opera- 
tions, owing  to  the  difficulty  of  getting  union  of  the  loose  segment 
of  the  jaw. 

The  canine  tooth  upon  either  side  of  the  lower  jaw  is  extracted, 
and  an  incision  made  from  each  corner  of  the  mouth,  through  the 
lower  lip,  gum,  and  periosteum,  down  to  the  bone,  and  continued 
downward,  in  the  neck,  through  the  skin,  fat,  and  platysma  as  far 
as  the  hyoid  bone. 

Corresponding  to  the  place  upon  either  side  where  the  canine 
tooth  has  been  extracted  the  lower  jaw  is  sawn  through,  from  its 
upper  border  downward  to  its  lower  border;  this  may  be  done  with 
the  chain,  wire,  or  flat  saw. 

The  soft  parts,  which  correspond  to  the  floor  of  the  mouth  and 
which  are  attached  to  the  middle,  loose  segment  of  the  jaw-bone,  are 
separated  upon  the  inner  aspect  of  the  bone,  and  the  flap  of  soft 
parts,  which  includes  the  free  middle  segment  of  the  bone,  is  re- 
flected downward. 

The  lingual  arteries  may  be  ligated  and  diseased  glands  re- 
moved through  the  incisions  in  the  neck  previous  to  amputating  the 
tongue,  or  the  arteries  may  be  clamped  and  ligated  in  the  stump 
after  the  tongue  has  been  cut  away.  We  gain  free  access  to  the 
floor  of  the  mouth,  tonsils,  etc.,  in  this  operation. 

The  segments  of  the  jaw  are  finally  wired  together  and  the 
incisions  closed  except  the  lower  part,  upon  one  or  both  sides,  which 
may  be  left  open  and  packed  for  drainage. 

Extirpation  of  Half  of  the  Tongue  (Whitehead). — The  patient 
may  be  placed  in  a  half-sitting  posture.  Anaesthesia  is  not  complete. 
A  liberal  dose  of  morphin  may  be  administered  hypodermically 
shortly  before  the  operation,  and  only  sufficient  chloroform  used  to 
keep  the  patient  fairly  quiet.  In  this  way  sufficient  reflex  is  retained 
to  enable  the  patient  to  keep  the  larynx  clear  of  blood  by  coughing 
and  expectorating. 

This  operation  is  advisable  when  only  half  of  the  tongue  is  to 


178  NECK  AND  TONGUE. 

be  removed,  or,  if  the  whole  tongue  is  to  be  extirpated,  where  the 
disease  is  limited  and  has  not  involved  the  floor  of  the  mouth. 

One  or  both  lingual  arteries  may  be  previously  tied  through  a 
small  incision  upon  either  side  of  the  neck. 

The  jaws  are  separated  with  a  gag  and  the  mouth  held  wide  open 
with  flat  retractors  placed  in  either  corner.  A  strong  silk  suture  is 
passed  through  the  tip  of  the  tongue,  and  with  this  as  a  tractor  the 
tongue  is  drawn  well  forward  and  split  down  the  middle  with  sharp 
scissors.  The  diseased  half  of  the  tongue  is  then  separated  from  the 
floor  of  the  mouth  and  amputated  as  far  back  toward  the  root  of 
the  organ  as  desired.  If  the  lingual  artery  has  not  been  tied  as  a 
preliminary  step  to  the  operation,  the  bleeding  vessel  must  be  seized 
with  the  artery  forceps  in  the  stump  of  the  tongue  and  ligated.  In 
excising  a  portion  of  the  tongue  one  should  cut  wide  of  the  apparent 
diseased  area.  If  the  disease  has  approached  near  the  middle  line 
it  is  probably  better  to  sacrifice  the  whole  tongue,  in  which  case  the 
second  half  of  the  tongue  may  be  amputated  in  a  similar  manner. 

This  operation  will  probably  suffice  for  early  cases  where  the 
floor  of  the  mouth  and  the  lymphatics  are  not  yet  involved. 


PART  IV. 

THE  THORAX. 


THE  SURGICAL  ANATOMY  OF  THE  THORACIC  WALL. 

The  Skeleton  of  the  Thorax. — The  thorax  consists  of  a  conical 
cage  of  bone  and  cartilage.  Entering  into  its  construction  are  the 
dorsal  vertebrae,  ribs,  sternum,  and  interposed  costal  cartilages.  The 
spaces  between  the  ribs  and  costal  cartilages  are  filled  in,  and  the 
walls  of  the  chest  thus  completed,  by  the  intercostal  muscles. 

The  thoracic  cavity  is  rather  cone-shaped,  with  its  base  below 
and  its  small  end  above,  and  is  somewhat  flattened  from  before  back- 
ward. 

The  upper  orifice  of  the  thorax  is  kidney-shaped,  narrow  from 
before  backward,  and  broader  from  side  to  side.  It  is  bounded  in 
front  by  the  upper  border  of  the  sternum,  behind  by  first  dorsal 
vertebra,  and  laterally,  on  each  side,  by  the  first  rib.  The  first  rib 
is  set  very  obliquely;  so  that  its  anterior  end  strikes  a  much  lower 
level  than  its  posterior  end.  The  upper  border  of  the  sternum  is 
opposite  the  intervertebral  cartilage  between  the  second  and  third 
dorsal  vertebras. 

The  lower  opening  of  the  thorax  is  large.  It  is  bounded  by  the 
lower  border  and  tip  of  the  twelfth  rib,  the  tip  of  the  eleventh  and 
the  costal  cartilages  of  the  tenth,  ninth,  eighth,  and  seventh  ribs. 
Anteriorly,  in  the  middle  line,  is  the  ensiform  cartilage;  posteriorly 
is  the  body  of  the  last  dorsal  vertebra. 

A  transverse  section  through  the  middle  of  the  thoracic  cavity 
shows  it  to  be  rather  heart-shaped,  owing  to  the  projection  forward 
of  the  bodies  of  the  vertebras.  On  either  side  of  the  vertebral  col- 
umn there  is  a  longitudinal  recess,  which  serves  to  deepen  the  space 
for  the  accommodation  of  the  lungs;  this  is  called  the  fossa  pul- 
monis. The  cartilages  of  the  lower  ribs,  the  seventh  to  the  tenth, 
meet  at  the  lower  end  of  the  sternum  and  form  an  angle  the  apex 
of  which  corresponds  to  the  ensiform  cartilage.  This  is  known  as 
the  costal  angle. 

The  thoracic  cavity  is  closed  in,  below,  by  the  diaphragm,  which 
projects  upward,  dome-like,  into  the  cavity  of  the  chest,  forming  its 

(179) 


180  THORAX. 

floor  and  at  the  same  time  the  roof  of  the  abdominal  cavity.  By  the 
projection  of  the  diaphragm  upward  into  the  chest  the  capacity  of 
the  chest  cavity  is  diminished  and  that  of  the  abdomen  correspond- 
ingly increased.  In  the  living  body  the  chest  appears  to  be  broader 
above,  at  the  shoulders,  than  below  at  the  waist;  this  appearance  is 
due  to  the  broad  shoulder  girdle,  which  partially  encircles  the  chest 
above  and  which  is  made  up  of  the  clavicle  and  the  scapula  of  either 
side. 

The  space  within  the  chest  consists  of  an  air-tight  compartment 
on  either  side,  each  containing  one  of  the  lungs,  and  a  middle  space 
called  the  mediastinum,  in  which  are  lodged  the  heart  and  the  great 
vessels  at  its  base,  the  trachea,  oesophagus,  thoracic  duct,  and  the 
thymus  gland  or  its  remains. 

The  Dorsal  Vertebra.  —  These  are  twelve  in  number  and 
form  the  back  part  of  the  skeleton  of  the  chest.  They  give  stability 
to  the  thorax  and  at  the  same  time,  on  account  of  the  presence  of 
the  elastic  intervertebral  pads,  free  motion  is  allowed  in  all  direc- 
tions. 

This  part  of  the  vertebral  column  shows  a  sagittal  curve  with 
its  concavity  forward  and  a  slight  lateral  curve  with  its  concavity 
toward  the  left  (aorta). 

The  Eibs  are  twelve  in  number  (may  be  eleven  or  thirteen)  on 
each  side.  They  are  flat  bones  articulated  behind  to  the  vertebras 
and  directed  obliquely  downward  and  forward.  They  form  the  bony 
frame-work  of  the  back,  sides,  and  part  of  the  front  of  the  chest. 

The  lower  the  rib  is  situated,  the  greater  is  its  inclination  down- 
ward.   They  increase  in  length  from  the  first  to  the  eighth. 

The  first  to  the  seventh  are  true  ribs:  i.e.,  they  are  each  con- 
nected individually,  through  their  cartilages,  with  the  sternum. 

The  eighth  to  the  twelfth  are  false  ribs:  their  cartilages  do  not 
articulate  with  the  sternum.  The  eighth,  ninth,  and  tenth  ribs  are 
indirectly  connected  with  the  sternum  through  the  junction  of  their 
respective  costal  cartilages  with  those  of  the  ribs  which  immediately 
adjoin  them  above. 

The  eleventh  and  twelfth  are  floating  ribs;  they  are  short  and 
their  cartilages  are  free. 

The  lower  border  of  each  rib,  upon  its  inner  aspect,  is  grooved 
for  the  lodgment  of  the  corresponding  intercostal  vein,  artery,  and 
nerve,  that  being  their  order  from  above  downward. 

The  first  rib  is  important  surgically.    It  is  very  short,  and  its 


SURGICAL  ANATOMY  OF  THE  THORACIC  WALL.  181 

surfaces  look  almost  directly  upward  and  downward.  It  is  set  so 
obliquely  that  its  posterior  end,  head,  articulates  with  the  upper 
part  of  the  body  of  the  first  dorsal  vertebra,  whereas  its  anterior 
end,  at  its  attachment  to  the  sternum,  is  upon  a  level  with  the  inter- 
vertebral pad  between  the  second  and  third  dorsal  vertebras.  The 
inner  border  of  this  rib  presents  a  tubercle  for  the  attachment  of 
the  scalenus  anticus  muscle;  external  to  this  tubercle,  upon  the 
upper  surface  of  the  rib,  there  is  a  groove  for  the  subclavian  artery. 
The  subclavian  vein  also  passes  across  the  upper  surface  of  the  first 
rib,  but  internally  to  the  artery,  the  tendon  of  the  scalenus  anticus 
being  interposed  between  the  two  vessels. 

The  inner  border  of  the  first  rib  is  in  direct  relation  with  the 
dome  of  the  pleura  and  the  apex  of  the  lung. 

The  Costal  Caetilages. — These  are  the  elastic  bands  which 
join  the  ribs  to  the  sternum  (except  the  eleventh  and  twelfth).  The 
cartilage  of  the  first  rib  is  very  short.  The  first  and  second  costal 
cartilages,  as  they  pass  to  the  sternum,  are  directed  somewhat  down- 
ward like  their  ribs.  The  cartilage  of  the  second  rib  articulates 
with  the  sternum  at  the  junction  of  the  manubrium  with  the  glad- 
iolus. The  cartilage  of  the  third  rib  is  directed  horizontally;  the 
cartilages  of  the  fourth,  fifth,  sixth,  and  seventh  ribs  are  directed 
upward  with  increasing  obliquity  as  they  pass  to  the  sternum.  The 
cartilages  of  the  eighth,  ninth,  and  tenth  make  quite  a  sharp  turn 
upward  toward  the  sternum  at  the  angle  of  junction  with  their  ribs, 
and  do  not  reach  the  sternum  directly,  but  are  fixed  each  to  the 
cartilage  immediately  above,  and  finally,  through  the  junction  of  the 
cartilage  of  the  eighth  rib  with  that  of  the  seventh,  to  the  sternum. 
The  cartilages  of  the  eleventh  and  twelfth  ribs  are  short  and  free. 

The  Steenum. — This  bone  is  rarely  fractured,  owing  to  the 
elasticity  of  the  parts  with  which  it  articulates.  It  consists  of  a 
manubrium,  or  handle;  a  gladiolus,  or  body;  and  a  cartilaginous  tip, 
the  ensiform  or  xiphoid  cartilage.  The  junction  between  the  manu- 
brium and  the  body  is  marked  by  a  prominent  transverse  line,  and 
presents  an  angle  directed  forward:  angulus  Ludovici.  This  trans- 
verse ridge,  which  is  readily  felt  under  the  skin,  is  an  important 
landmark  in  counting  the  ribs:  it  corresponds  to  the  articulation  of 
the  costal  cartilage  of  the  second  rib  with  the  sternum. 

The  ensiform  cartilage  varies  in  length  and  shape;  its  lower 
extremity  is  usually  on  a  level  with  the  tenth  dorsal  vertebra;  it 
may  be  bifurcated  or  deflected  to  one  side.     The  junction  of  the 


182  THORAX. 

ensiform  cartilage  with  the  body  of  the  sternum  corresponds  with 
the  line  that  marks  the  lower  border  of  the  heart  as  it  lies  within 
the  chest  behind  the  sternum. 

The  Muscles  of  the  Chest  Wall.  The  Intercostal  Muscles 
are  placed  between  the  ribs  and  costal  cartilages,  and  consist  of  two 
sets:    external  and  internal. 

The  External  Intercostals.  —  The  fibers  of  the  external  inter- 
costals  have  a  direction  similar  to  those  of  the  external  oblique 
muscle  of  the  abdomen:  that  is,  from  above  downward  and  forward. 
In  front,  between  the  costal  cartilages,  the  muscular  fibers  are  ab- 
sent, their  place  being  taken  by  aponeurotic  bands,  the  ligamenta 
intercostalia  anterior,  which  represent  the  muscles. 

The  Internal  Intercostals. — The  direction  of  the  fibers  of  the 
internal  intercostal  muscles  is  the  reverse  of  those  of  the  external. 
They  correspond  to  the  internal  oblique  muscle  of  the  abdomen, 
and  their  fibers  have  a  similar  direction:  upward  and  forward.  Be- 
hind, the  internal  intercostals  are  deficient,  their  place  being  occu- 
pied by  aponeurotic  sheaths:    the  ligamenta  intercostalia  posterior. 

The  Triangularis  Sterni  is  situated  anteriorly  within  the 
chest.  It  is  a  thin  sheet  of  muscle  which  is  attached  along  the 
lateral  border  of  the  posterior  aspect  of  the  sternum.  It  spreads 
upward  and  outward  in  four  or  five  processes,  which  are  attached 
separately  to  the  inner  surfaces  of  the  cartilages  of  the  second  to 
the  sixth  ribs.  The  internal  mammary  artery  is  located  between 
this  muscle  and  the  costal  cartilages.  The  triangularis  sterni  is  the 
transversus  thoracis  anterior  of  Henle. 

The  Musculi  Subcostales  are  a  few  sets  of  muscular  fibers 
that  are  found  upon  the  internal  surfaces  of  the  posterior  ends  of 
the  ribs  near  the  vertebral  column;  the  direction  of  the  fibers  of 
these  muscles  is  similar  to  that  of  the  internal  intercostals:  they 
reach  from  the  inner  surface  of  one  rib  to  the  first  or  second  rib 
above.  These  muscles  correspond  to  the  musculus  transversus 
thoracis  posterior  of  Henle,  and  together  with  the  triangularis  sterni 
are  the  analogues  of  the  transversus  abdominis,  the  most  internal, 
deepest,  of  the  flat  muscles  of  the  abdomen. 

The  Fasciae  of  the  Chest. — A  thin  fascia  covers  the  outer  surface 
of  the  ribs  and  the  external  intercostals.  A  similar  fascia  is  spread 
over  the  inner  surface  of  the  ribs  and  the  internal  intercostals,  tri- 
angularis sterni,  and  subcostales.  This  fascia  corresponds  to  the 
fascia  transversalis  of  the  abdomen,  and  is  known  as  the  fascia  endo- 


SURGICAL  ANATOMY  OF  THE  THORACIC  WALL.  183 

thoracica.  The  fascia  endothoracica  is  also  spread  over  the  thoracic 
surface  of  the  diaphragm.  It  lines  the  whole  inner  surface  of  the 
thoracic  cavity,  and  is  everywhere  interposed  between  the  parietal 
layer  of  the  pleura  and  the  inner  surface  of  the  chest,  serving  thus 
to  bind  the  pleura  to  the  chest  wall  and  at  the  same  time  to 
strengthen  it.  Upon  the  posterior  surface  of  the  sternum  this  fascia 
forms  a  strong  fibrous  layer.  Above  it  projects  into  the  root  of 
the  neck  together  with  the  dome  of  the  pleura,  which  it  strengthens 
and  fixes  to  the  vertebra?  and  to  the  deep  surface  of  scaleni  muscles, 
etc. 

The  Internal  Mammary  Artery  supplies  the  front  part  of  the 
intercostal  spaces  and  the  diaphragm  and  gives  perforating  branches 
to  the  muscles  of  the  chest  and  to  the  mammary  gland.  At  its  origin 
from  the  first  part  of  the  subclavian  artery  it  lies  behind  the  sub- 
clavian vein,  resting  upon  the  pleura,  and  is  crossed  by  the  phrenic 
nerve.  It  passes  down  into  the  thoracic  cavity  and  descends  along- 
side of  the  sternum,  a  distance  of  from  5  to  10  mm.  intervening 
between  it  and  the  lateral  border  of  this  bone.  Behind  the  seventh 
costal  cartilage  the  internal  mammary  artery  divides  into  the 
musculo-phrenic  and  the  superior  epigastric.  The  musculo-phrenic 
continues  downward  parallel  with  the  free  border  of  the  ribs,  sup- 
plying branches  to  the  intercostal  spaces.  The  superior  epigastric 
enters  the  posterior  sheath  of  the  rectus,  anastomosing  with  the  deep 
epigastric,  which  is  derived  from  the  external  iliac,  and  in  this  way 
forms  an  important  communication  between  this  trunk  and  the  sub- 
clavian. The  internal  mammary  artery  is  accompanied  by  two  veins, 
one  upon  either  side,  but  above  these  two  unite  to  form  a  single 
vein,  which  lies  to  the  inner  side  of  the  artery.  The  artery  is  also 
accompanied  by  a  chain  of  lymphatic  glands. 

Within  the  chest  the  artery  rests  upon  the  costal  cartilages  and 
the  internal  intercostal  muscles,  alongside  the  sternum,  and  is  sepa- 
rated from  the  parietal  pleura  by  the  fascia  endothoracica  and  the  tri- 
angularis sterni  muscle.  Opposite  each  intercostal  space  the  internal 
mammary  gives  off  an  intercostal  branch,  which,  passing  outward, 
divides  into  two,  and  these,  anastomosing  with  the  intercostal 
branches  from  the  aorta,  serve  to  establish  a  communication  between 
the  subclavian  and  the  aorta.  These  intercostal  branches  are  located 
between  the  internal  and  the  external  intercostal  muscles  close  to 
the  upper  and  lower  borders  of  the  contiguous  ribs.  The  internal 
mammary  gives  off  perforating  branches,  which  pass  forward  through 


184  THORAX. 

the  intercostal  spaces  to  supply  the  muscles  of  the  breast  and  the 
mammary  glands.  Those  which  pass  through  the  second,  third,  and 
fourth  intercostal  spaces  are  large,  and  are  distributed  to  the  mam- 
mary gland. 

The  Diaphragm. — The  lower  orifice  of  the  thorax  is  closed  in 
by  the  diaphragm.  This  is  a  musculo-tendinous  partition  which 
separates  the  thorax  from  the  abdominal  cavity.  It  forms  the  floor 
of  the  thoracic  cavity  and  the  roof  of  the  abdomen.  The  thoracic 
surface  of  the  diaphragm  is  covered  by  the  fascia  endothoracica  and 
the  diaphragmatic  portion  of  the  parietal  pleura.  Its  middle  part 
from  before  backward  forms  the  floor  of  the  mediastinum,  and  upon 
either  side  of  this  it  forms  the  bottom  of  each  pleural  cavity. 

The  position  of  the  diaphragm,  immediately  after  death,  corre- 
sponds with  that  found  at  the  end  of  quiet  expiration  during  life, 
but  after  a  short  time,  owing  to  the  further  collapse  of  the  lungs, 
it  reaches  to  a  still  higher  level. 

Luschka  places  the  highest  point  reached  by  the  diaphragm 
at  the  end  of  forced  expiration  upon  the  right  side  at  the  level  of 
the  fourth  rib.  Most  authors  say  that  this  is  too  high  and  give,  in- 
stead, the  fourth  intercostal  space.  Upon  the  left  side  the  dia- 
phragm does  not  reach  as  high  as  upon  the  right  by  the  breadth  of 
one  rib. 

The  upper  orifice  of  the  thoracic  cavity  is  shut  in  on  either  side 
hy  the  arching  subclavian  artery,  scalenus  anticus  and  medius  mus- 
cles, and  the  fascia  endothoracica.  This  fascia  is  intimately  blended 
with  the  dome  of  the  pleura,  and  attaches  the  same  to  the  adjacent 
fixed  points. 

THE  REGIONS  OF  THE  THORAX. 

The  following  imaginary  lines  serve  to  facilitate  the  location  of 
points  upon  the  thorax : — 

1.  The  midsternal,  which  passes  through  the  middle  of  the 
sternum. 

2.  The  lateral  sternal,  which  corresponds  to  the  lateral  border 
of  the  sternum. 

3.  The  mammary,  which  is  drawn  through  the  nipple. 

4.  The  parasternal,  which  is  drawn  midway  between  the  lateral 
border  of  the  sternum  and  the  mammary  line. 

5.  The  axillary,  which  is  located  midway  between  the  anterior 
and  the  posterior  borders  of  the  axilla. 


REGIONS  OF  THE  THORAX.  185 

6.  The  scapular  passes  through  the  lower  angle  of  the  scapula. 
The  chest  is  divided  into  a  number  of  regions  as  follows: — 

1.  The  sternal. 

2.  The  upper  anterior  pectoral,  which  is  subdivided  into  a 
clavicular,  an  infraclavicular,  and  a  mammary. 

3.  The  lower  anterior  pectoral. 

4.  The  lateral  pectoral. 

The  Sternal  Region. — This  region  corresponds  to  the  sternum. 
It  is  depressed  below  the  level  of  the  rest  of  the  chest,  especially 
in  muscular  subjects  and  in  females. 

The  skin  of  this  region,  in  the  male,  is  usually  covered  with  hair 
and  is  rich  in  sweat-glands.  The  subcutaneous  tissue  is  poor  in  fat 
and  allows  ready  palpation  of  the  sternum  beneath.  The  skin  and 
periosteum  covering  the  sternum  are  so  intimately  blended  with  each 
other  that  separation  between  these  two  layers  is  somewhat  difficult, 
and,  therefore,  collections  of  blood  or  pus  beneath  the  skin  in  this 
region  remain  circumscribed,  as  is  the  case  in  the  subcutaneous  tissue 
of  the  scalp.  Above,  we  observe  the  upper  notched  border  of  the 
sternum  with  the  sterno-clavicular  articulation  upon  either  side  and 
the  attachment  of  the  tendon  of  the  sterno-mastoid.  Below  is  the 
ensiform  cartilage,  to  which  is  attached  the  linea  alba.  The  junction 
of  the  manubrium  with  the  body  of  the  sternum  is  marked  by  a 
prominent  transverse  ridge  and  presents  an  angle  directed  forward: 
the  angle  of  Ludovici.  The  sternum  forms  the  anterior  wall  of  the 
mediastinal  space,  and  its  posterior  surface  is  in  close  relation  with 
the  pleura  and  the  edges  of  the  lungs.  Below,  the  heart,  inclosed 
in  the  pericardial  sac,  lies  close  behind  the  sternum. 

The  Upper  Anterior  Pectoral  Region. — This  area  corresponds  to 
the  region  of  the  pectoralis  major  muscle,  and  shows  the  prominence 
of  the  breast  surmounted  by  the  nipple  and  the  areola.  The  skin  is 
soft,  especially  in  women,  and  during  lactation  is  marked  by  blue 
lines,  which  correspond  to  large  superficial  veins.  The  skin  is  freely 
movable,  owing  to  the  looseness  of  the  subcutaneous  tissue,  which 
is  rich  in  fat  and  within  which  the  mammary  gland  is  contained. 
The  mammary  gland  is  freely  movable  upon  the  underlying  pec- 
toralis major  muscle.  The  anterior  surface  of  the  pectoralis  major 
is  covered  by  a  thin,  cellular  fascia,  which  also  lines  the  posterior 
aspect  of  this  muscle.  Beneath  the  pectoralis  major  are  the  pec- 
toralis minor  and  the  subclavius  muscle.  The  pectoralis  major  and 
minor  form  the  front  wall  of  the  axilla. 


186  THORAX. 

The  Pectoealis  Majoe  is  a  broad,  flat  muscle  which  occupies 
all  of  this  region.  It  takes  its  origin  from  the  cartilages  of  the  six 
or  seven  upper  ribs  and  from  the  edge  of  the  sternum:  the  sternal 
portion  of  the  muscle.  It  also  arises  from  the  inner  half  of  the 
anterior  surface  of  the  clavicle:  the  clavicular  portion  of  the  mus- 
cle. From  these  points  of  origin  the  fibers  converge  to  form  a  flat 
tendon,  about  two  inches  broad,  which  is  attached  to  the  outer  edge 
or  lip  of  the  bicipital  groove:  a  depression  which  marks  the  upper 
part  of  the  front  of  the  humerus.  The  pectoralis  major  muscle  is 
covered  by  a  thin  fascia,  which  dips  down  between  its  fasciculi  and 
from  which  the  overlying  fat  and  mammary  gland  are  readily  sepa- 
rated. This  fascia  is  rich  in  lymphatics,  which  may  become  involved 
in  disease  of  the  mammary  gland.  Below,  this  fascia  is  continuous 
with  the  superficial  fascia  which  covers  the  abdominal  muscles  and 
laterally  with  that  which  covers  the  serratus  magnus.  It  dips  down 
into  the  space  between  the  deltoid  and  the  pectoralis  major,  and  is 
there  continuous  with  the  loose  fascia  that  invests  the  pectoralis 
minor  and  the  posterior  surface  of  the  pectoralis  major. 

The  Pectoealis  Minoe. — This  muscle  is  exposed  by  dividing 
the  tendon  of  the  pectoralis  major  close  to  its  insertion  and  reflect- 
ing the  muscle  downward.  The  pectoralis  minor  arises  from  the  tip 
of  the  coracoid  process;  passing  downward  and  inward  and  becoming 
broader,  it  is  attached  to  the  third,  fourth,  and  fifth  ribs.  The 
pectoralis  minor  is  invested  by  a  fascia  which  is  continued  upward 
and  inward  beyond  the  upper  border  of  the  muscle,  covering  in  the 
first  part  of  the  axillary  artery  and  adjoining  structures  and  the  sub- 
clavius  muscle.  This  layer  of  fascia  is  called  the  costo-coracoid 
membrane  and  is  attached  to  the  under  surface  of  the  clavicle  and 
to  the  first  rib.  It  is  somewhat  thickened,  and  perforated  by  various 
vascular  and  nervous  branches,  which  pass  to  and  from  the  axillary 
vessels  and  adjacent  nerves. 

The  Subclavius  Muscle. — This  muscle  is  exposed  after  the 
costo-coracoid  membrane  has  been  removed.  It  arises  from  the 
under  surface  of  the  clavicle  and  passing  downward  and  inward  is 
attached  to  the  cartilage  of  the  first  rib. 

This  upper  anterior  pectoral  region  may  be  considered  as  the 
clavicular,  the  infraclavicular,  and  the  mammary  regions. 

The  Claviculae  Eegion.  —  The  clavicle  can  be  readily  pal- 
pated beneath  the  freely  movable  integument  which  covers  it  from 
its  inner  end,  where  it  articulates  with  the  sternum,  to  its  outer  end, 


REGIONS  OF  THE  THORAX.  187 

where  it  articulates  with  the  acromion  process  of  the  scapula.  The 
acromion  process  of  the  scapula  forms  the  most  external  and  promi- 
nent point  of  the  shoulder. 

Beneath  the  skin  in  the  clavicular  region  are  found  the  platysma 
and  the  deep  fascia. 

To  the  upper  surface  and  posterior  border  of  the  clavicle  are 
attached,  internally,  the  sterno-mastoid  muscle,  and  externally  the 
trapezius.  To  the  inner  half  of  the  front  surface  of  the  clavicle  is 
attached  the  pectoralis  major  muscle  (clavicular  portion),  and,  to 
its  outer  half,  the  deltoid  muscle. 

The  under  surface  of  the  clavicle  shows,  at  its  inner  end,  the 
attachment  of  the  rhomboid  ligament.  This  ligament  extends  be- 
tween the  under  surface  of  the  clavicle  and  the  cartilage  of  the  first 
rib.  External  to  this  the  subclavius  muscle  arises  from  the  under 
surface  of  the  clavicle. 

The  inferior  surface  of  the  outer  end  of  the  clavicle  is  con- 
nected with  the  coracoid  process  of  the  scapula  by  strong  ligamentous 
bands. 

Beneath  the  clavicle,  between  it  and  the  first  rib,  the  blood- 
vessels and  nerves  pass  from  the  root  of  the  neck  into  the  axilla. 

The  Infraclavicular  Begion. — This  is  the  region  below  the 
clavicle.  Between  the  pectoralis  major  and  the  deltoid  muscle,  close 
to  the  clavicle,  there  is  a  triangular  depression,  the  fossa  of  Mohren- 
heim:   the  infraclavicular  fossa. 

In  the  space,  or  groove,  between  the  pectoralis  major  and  the 
deltoid  are  lodged  the  cephalic  vein  and  the  descending  branch  of 
the  acromio-thoracie  artery,  which  is  given  off  from  the  axillary. 
If  the  two  muscles  are  widely  separated,  we  expose  the  upper  part 
of  the  pectoralis  minor,  covered  by  its  fascia,  some  loose  connective 
tissue  and  fat,  and  the  coracoid  process.  This  process  is  readily  felt 
underneath  the  skin,  and  in  thin  persons  can  be  seen. 

If  the  pectoralis  major  is  cut  away  from  its  attachment  to  the 
clavicle  and  from  the  upper  part  of  the  sternum  and  reflected  down- 
ward, the  infraclavicular  region  proper  is  uncovered.  The  pectoralis 
minor  muscle  is  now  more  freely  exposed.  The  cephalic  vein  may 
be  seen  passing  from  without  inward  across  the  pectoralis  minor 
into  a  mass  of  fat  and  connective  tissue  on  the  inner  side  of  the 
muscle,  where  it  disappears  through  an  opening  in  the  costo-coracoid 
membrane  to  reach  the  first  part  of  the  axillary  vein,  which  lies 
underneath  this  membrane. 


188  THORAX. 

The  acromio-thoracic  and  branches  of  the  superior  thoracic 
which  are  derived  from  the  axillary  artery  are  seen  to  emerge  through 
openings  in  the  costo-coracoid  membrane,  as  is  also  the  external 
anterior  thoracic  nerve,  which  supplies  the  pectoralis  major. 

The  costo-coracoid  membrane  is  a  sheet  of  fascia  which  is  con- 
tinued from  the  inner  or  upper  border  of  the  pectoralis  minor  mus- 
cle upward  and  inward,  and  is  attached  to  the  under  surface  of  the 
clavicle  and  to  the  first  rib;  it  covers  in  the  first  part  of  the  axillary 
artery  and  the  structures  that  accompany  it  and  the  subclavius  mus- 
cle. When  the  costo-coracoid  membrane  is  removed,  we  expose  the 
first  part  of  the  axillary  artery  and  its  acromio-thoracic  and  superior 
thoracic  branches,  the  cords  of  the  brachial  plexus,  which  lie  above 
the  artery,  and  the  axillary  vein,  which  lies  below  and  internal  to  the 
artery.  The  cephalic  vein  may  be  seen  passing  across  the  axillary 
artery  to  enter  the  axillary  vein.  All  these  structures  are  gathered 
together  into  a  single  bundle,  and  are  accompanied  by  a  mass  of 
fat,  connective  tissue,  and  lymphatics  (see  Fig.  221). 

The  Mammaey  Eegion  (Beeast).  —  The  mammary  gland  is 
rudimentary  in  the  male  and  naturally  well  developed  in  the  female. 
It  rests  upon  the  pectoralis  major  muscle  from  the  third  to  the  sixth 
rib.  In  unmarried  and  in  young  females  it  is  hemispheroidal,  firm, 
and  projects  forward;  but  after  child-bearing,  and  especially  in  some 
races  more  than  others,  it  is  pendulous,  and  hangs  down  over  the 
lower  part  of  the  thorax. 

The  skin  of  this  region  is  thin  and  fine  and  is  freely  movable 
upon  the  underlying  tissue.  The  superficial  veins  may  show  through 
the  skin  as  irregular  blue  streaks.  The  skin  of  the  nipple  is  espe- 
cially thin  and  pigmented,  and  may  be  fissured  and  split,  and  shows 
the  orifices  of  the  milk-ducts,  fifteen  to  twenty  in  number,  as  very 
fine,  needle-point  openings;  through  these  infection  may  reach  the 
mammary  gland  tissue  proper. 

In  the  unpregnant  the  nipple  is  depressed  and  pinkish,  but  is 
prominent  and  dark  colored  during  pregnancy.  The  nipple  is  sur- 
rounded by  a  pigmented  area,  areola,  which  is  fixed  to  the  under- 
lying tissue  and  marked  by  little  nodules  which  correspond  to  se- 
baceous and  sweat-glands. 

In  the  unmarried  the  mammary  gland  proper  is  small,  the  promi- 
nence of  the  breast  being  due  chiefly  to  the  abundance  of  the  fatty 
tissue  in  which  the  gland  is  imbedded.  It  does  not  reach  its  full 
development  until  after  pregnancy.     The  mammary  gland  is  a  tegu- 


REGIONS  OF  THE  THORAX.  189 

mentary  organ  inclosed  within  its  own  proper  fibrous  capsule  and 
lodged  in  the  subcutaneous  fat.  It  consists  of  a  number  of  lobules, 
which  are  separate  and  distinct  from  each  other;  so  that  the  secre- 
tion of  milk  and  nursing  may  be  continued  even  after  one  or  more 
lobules  have  become  the  seat  of  a  suppurative  process.  Between 
the  mammary  gland  and  the  anterior  surface  of  the  pectoralis  major 
muscle  there  is  a  layer  of  loose  fatty  tissue,  which  permits  the  gland 
to  be  freely  moved  about  upon  the  surface  of  the  muscle. 

Occasionally  a  process  of  gland  tissue  almost  entirely  discon- 
nected from  the  main  gland  may  be  found  lying  under  the  border 
of  the  pectoralis  major,  dipping  beneath  the  muscle  into  the  axilla. 
This  process  of  gland  tissue  is  often  difficult  to  recognize.  All  the 
ducts  of  the  gland  converge  from  the  periphery  toward  the  nipple; 
they  may  become  occluded  and  distended,  giving  rise  to  cystic  tumors 
whose  contents  consist  of  milk  or  of  a  buttery  material:  galactocele. 

The  arteries  of  the  breast  consist  of  perforating  branches  from 
the  internal  mammary,  especially  the  second  and  third  and  branches 
of  the  long  thoracic  from  the  axillary.  Of  the  veins,  the  superficial 
ramify  beneath  the  skin  and  the  deep  ones  accompany  the  arteries. 

The  lymphatics  are  important  and  of  these  there  are  two  sets: 
those  of  the  integument  and  those  which  drain  the  gland  proper. 
The  lymphatics  of  the  integument  are  very  superficial  and  numerous, 
especially  upon  the  nipple  and  in  the  areola;  corresponding  to  the 
region  of  the  areola,  they  form  a  fine  capillary  net-work  which 
spreads  outward  toward  the  periphery,  some  branches  dipping  in- 
ward to  enter  a  plexus  which  surrounds  the  milk-ducts  beneath  the 
skin  of  the  areolar  region.  The  lymphatics  from  the  gland  proper, 
from  the  acini  and  substance  of  the  gland,  are  abundant.  Accord- 
ing to  Sappay,  they  all  tend  toward  the  surface  and  end  as  good- 
sized  vessels  in  the  plexus  already  mentioned  which  surrounds  the 
milk-ducts  beneath  the  skin  of  the  areola.  The  lymph  from  this 
subareolar  plexus  is  collected  into  two  main  channels:  one  above 
and  one  below  the  nipple.  These  lymphatic  vessels  pass  outward 
toward  the  outer  border  of  the  gland,  and,  after  being  joined  by  one 
or  two  vessels  from  the  periphery  of  the  gland,  terminate  in  the 
nearest  lymphatic  nodes,  which  are  found  near  the  anterior  wall  of 
the  axilla  in  the  neighborhood  of  the  third  and  fourth  ribs,  being 
covered  usually  by  the  edge  of  the  pectoralis  major.  These  are,  as 
a  rule,  the  first  lymphatic  nodes  to  become  involved  in  disease  of 
the  mammary  gland.    The  lymphatic  nodes  in  the  root  of  the  neck 


190  THORAX. 

also  receive  tributaries  from  the  breast,  and  may  be  found  involved 
when  the  mammary  gland  is  diseased. 

The  Lower  Anterior  Pectoral  Region. — This  is  the  area  which 
lies  between  the  lower  limits  of  the  pectoralis  major  muscle  and 
the  free  border  of  the  ribs.  This  region  is  important  surgically  only 
on  account  of  the  structures  which  lie  beneath  it,  within  the  chest 
and  abdomen. 

The  Lateral  Pectoral  Begion. — This  space  is  included  between 
the  border  of  the  pectoralis  major  in  front  and  that  of  the  latissimns 
dorsi  behind.  It  presents  the  ribs  covered  by  serrations  of  the  ser- 
ratus  magnus  and  by  the  latissimus  dorsi  and  obliquus  abdominis 
externus. 

The  arteries  of  this  region  are  derived  from  the  axillary  (long 
thoracic)  and  intercostals.  The  posterior  thoracic  nerve  is  found  in 
this  region  descending  upon  the  serratus  magnus,  which  it  supplies. 

THE  MEDIASTINUM  AND  CONTENTS. 

The  mediastinum  is  a  space  within  the  chest,  between  the  two 
pleural  cavities,  which  is  occupied  by  the  heart  and  pericardium,  the 
thymus  or  its  remains,  the  trachea,  oesophagus,  aorta,  and  several 
nerves,  and  a  mass  of  loose  connective  tissue  and  lymphatics. 

Eather  more  of  the  space  lies  to  the  left  of  the  middle  line 
than  to  the  right.  It  is  limited  in  front  by  the  sternum,  behind  by 
the  vertebral  column,  and  its  floor  is  formed  by  the  diaphragm. 
Above,  the  loose  connective  tissue  of  this  space  is  continuous  into 
the  root  of  the  neck  with  that  which  surrounds  the  oesophagus  and 
trachea  and  the  great  vessels  in  the  neck.  Laterally  the  mediastinum 
is  walled  off  on  either  side  from  the  pleural  cavity  by  the  parietal 
pleura  (mediastinal  portion  of  the  parietal  pleura). 

The  mediastinum,  as  mentioned  above,  is  not  an  empty  space, 
but  is  fairly  closely  occupied  by  various  organs.  In  the  lower  part 
of  this  space,  in  front,  is  the  heart,  inclosed  within  its  pericardial 
sac;  behind  the  heart,  between  it  and  the  vertebral  column,  the 
space  is  not  large,  and  is  occupied  by  the  oesophagus,  thoracic  duct, 
thoracic  aorta,  vena  azygos,  vena  hemiazygos,  and  various  nerves. 
In  the  upper  part  of  the  mediastinum,  in  front,  is  the  thymus  or  its 
remains,  and  behind  this  the  trachea  and  oesophagus,  the  latter  lying 
just  in  front  of  the  vertebral  column.  Immediately  above  the  base 
of  the  heart  are  the  great  vessels  connected  with  the  heart — the  arch 


MEDIASTINUM  AND  CONTENTS. 


191 


of  the  aorta,  vena  cava  superior,  pulmonary  artery  and  its  branches 
— and  the  bifurcation  of  the  trachea.  A  number  of  lymphatic  glands 
which  communicate  with  the  lymphatics  of  the  neck  and  axilla  are 
packed  in  between  these  structures. 

The  Pericardium. — The  heart,  occupying  the  lower  anterior  part 
of  the  mediastinum,  lies  close  to  the  anterior  wall  of  the  chest 
(sternum)  inclosed  within  its  own  serous  sac,  the  pericardium.  The 
pericardium,  as  a  thin  serous  layer,  is  closely  applied  to  the  whole 
surface  of  the  heart  and  to  the  great  vessels  at  its  base  for  a  part  of 


?%?*- 


?>  m* 


Fig.  82.— Transverse  Section  through  Thorax  just  Above  the  Heart  and 
Root  of  the  Lungs.  A,  A,  aorta;  ES,  oesophagus;  LP  A,  left  pulmonary  artery; 
MP,  mediastinal  pleura  passing  forward  to  the  posterior  aspect  of  the  root 
of  the  lung;  PA,  pulmonary  artery;  PE,  pericardium;  PN,  phrenic  nerve; 
PP,  parietal  layer  of  pleura;  PS,  space  between  parietal  and  visceral  layers 
of  the  pleura;  RB,  right  bronchus;  RPA,  right  pulmonary  artery;  S,  ster- 
num; VA,  vena  azygos;  YC,  vena  cava  superior;  TP,  visceral  layer  pleura. 


their  extent;  above,  after  inclosing  the  first  or  ascending  part  of  the 
arch  of  the  aorta,  it  is  reflected  as  a  thin,  loose,  membranous  sac, 
which  completely  envelops  the  heart  and  is  attached  below  by  its 
broad  base  to  the  dome  of  the  diaphragm.  The  highest  limit,  or  the 
apex,  of  the  pericardial  sac  is  that  portion  which  incloses  the  first  part 
of  the  arch  of  the  aorta.  Its  broad  base,  which  is  below,  corresponds 
to  its  attachment  to  the  diaphragm.    The  pulmonary  artery  is  also 


192  THORAX. 

included  within  the  pericardial  sac  as  far  as  its  bifurcation,  but  its 
two  divisions  are  not  included.  The  vena  cava  superior  is  also 
partially  invested. 

In  front,  the  pericardial  sac  is  in  relation  with  the  sternum 
and  the  costal  cartilages,  from  which  it  is  separated  by  the  inter- 
posed pleura  and  the  edges  of  the  lungs.  Behind  the  lower  part  of 
the  sternum  there  is  a  triangular  space — with  its  apex  above  upon  a 
level  with  the  fourth  costal  cartilage,  a  little  to  the  left  of  the 
middle  line,  and  its  base  below,  corresponding  to  the  junction  of  the 
body  of  the  sternum  with  the  ensiform  cartilage:  i.e.,  on  a  level 
with  the  articulation  of  the  sixth  costal  cartilage — where  the  peri- 
cardium lies  in  direct  relation  with  the  posterior  surface  of  the 
sternum.  Corresponding  to  this  area  the  pleura  and  the  edge  of  the 
lung  are  not  interposed  between  the  sternum  and  the  pericardial 
sac.  Occasionally,  according  to  some  descriptions,  the  edge  of  the 
left  pleura  fails  to  reach  the  left  border  of  the  sternum  behind  the 
fifth  costal  cartilage  and  fifth  intercostal  space,  and  under  these 
circumstances  one  could  puncture  through  the  fifth  space  close  to 
the  left  border  of  the  sternum  and  enter  the  pericardial  sac  without 
meeting  the  pleura.  In  all  cases  the  edge  of  the  left  lung  is  notched 
in  this  region,  incisura  cardiaca;  so  that,  although  one  might  en- 
counter the  pleura  in  puncturing  in  this  situation,  he  would  not, 
in  any  case,  meet  the  lung.  Corresponding  to  the  incisura  cardiaca 
is  the  region  of  the  "cardiac  impulse,"  and  here  the  heart  is  most 
exposed.  Behind,  that  part  of  the  pericardial  sac  which  covers  the 
left  auricle  is  in  close  relation  with  the  oesophagus.  The  trachea 
bifurcates  just  above  and  close  to  that  part  of  the  pericardial  sac  that 
covers  the  left  auricle.  On  each  side  the  pericardium  is  firmly  ad- 
herent to  the  mediastinal  portion  of  the  parietal  pleura,  and  between 
the  apposed  layers  of  both  these  structures,  upon  either  side,  the 
phrenic  nerve  descends  in  its  course  to  reach  and  supply  the  dia- 
phragm. 

The  Heart. — The  heart,  inclosed  within  the  pericardial  sac,  is 
located  in  the  lower  anterior  part  of  the  mediastinum,  almost  com- 
pletely surrounded  by  the  lungs,  which  show  a  hollowed-out  cavity 
on  their  internal  surface  corresponding  to  the  size  and  shape  of 
the  heart.  The  impression  upon  the  left  lung  is  deeper  than  that 
upon  the  right. 

Behind  the  heart  is  the  vertebral  column,  and  in  the  space  be- 
tween the  heart  and  the  spinal  column,  in  the  lower  back  part  of 


MEDIASTINUM  AND  CONTENTS.  193 

the  mediastinum,  are  the  oesophagus,  accompanied  hy  the  pneumo- 
gastric  nerves;  the  thoracic  aorta  and  thoracic  duct;  the  vena 
azygos,  which  lies  to  the  right  of  the  vertebral  column;  and  the 
vena  hemiazygos,  which  lies  to  the  left  of  the  column. 

The  heart,  with  its  long  axis  directed  downward,  forward,  and 
to  the  left,  rests  with  its  posterior  surface,  which  is  composed  chiefly 
of  the  left  ventricle,  upon  the  central  tendon  of  the  diaphragm. 
Here  the  diaphragm  is  somewhat  flattened,  and  to  the  right  of  the 
middle  line  is  perforated  for  the  passage  of  the  vena  cava  inferior. 
This  vessel,  after  passing  through  the  diaphragm,  enters  almost  im- 
mediately the  lower  contiguous  part  of  the  right  auricle. 

The  anterior  surface  of  the  heart,  composed  mainly  of  the  right 
ventricle  and  auricle,  lies  close  to  the  posterior  surface  of  the  ster- 
num and  costal  cartilages,  from  which  it  is  separated,  for  the  most 
part,  hy  the  pleura  and  the  lungs,  these  being  interposed  between 
the  heart  and  the  sternum  and  costal  cartilages. 

The  base  of  the  heart,  which  is  directed  upward  and  backward 
toward  the  spinal  column,  is  made  up  of  the  auricles;  the  right 
auricle  is  placed  anteriorly,  and  receives  above  the  vena  cava  supe- 
rior and  below  the  vena  cava  inferior;  the  left  auricle  forms  the 
posterior  part  of  the  base,  lying  close  to  the  oesophagus,  and  receives 
the  pulmonary  veins  from  either  lung. 

The  apex  of  the  heart,  the  lowest  part  of  the  left  ventricle,  is 
found  in  the  fifth  left  intercostal  space  midway  between  the  para- 
sternal and  mammary  lines. 

Above  the  heart  are  the  arch  of  the  aorta,  with  the  superior 
vena  cava  placed  close  upon  the  right  side  of  its  first  or  ascending 
part,  the  pulmonary  artery  and  its  bifurcation,  the  bifurcation  of 
the  trachea,  and  a  mass  of  lymphatic  glands  and  fat. 

The  Outlines  of  the  Heart  upon  the  Chest  Wall. — The 
lower  border  of  the  heart  corresponds  to  the  line  of  junction  between 
the  body  of  the  sternum  and  its  ensiform  cartilage.  The  upper 
border  of  the  heart  corresponds  to  the  upper  border  of  the  third 
costal  cartilage.  To  the  right  of  the  sternum  lies  the  right  auricle, 
its  boundary  corresponding  to  a  curved  line  which  is  drawn  from  the 
articular  end  of  the  third  costal  cartilage  downward  and  through  the 
fifth  costal  cartilage  close  to  its  articulation  with  the  sternum.  The 
right  ventricle  reaches  over  for  a  considerable  distance  to  the  left 
of  the  sternum,  with  a  portion  of  the  left  ventricle  adjoining  and 
forming  the  left  border  of  the  heart.     The  apex,  the  extreme  end 


194 


THORAX. 


of  the  left  ventricle,  is  situated  in  the  fifth  intercostal  space  midway 
between  the  parasternal  and  the  mammary  lines. 

One-third  of  the  heart  lies  to  the  right  and  two-thirds  to  the 
left  of  the  middle  line. 

The  pulmonary  orifice,  valve,   corresponds   to   a   line  which  is 


Fig.  83.— Outline  of  Heart  and  Location  of  Valves.  A,  aortic  orifice,  left 
semilunar  valve  (dotted  line);  P,  orifice  of  pulmonary  artery,  right  semi- 
lunar valve;  T.M.,  line  of  right  and  left  auriculo-ventricular  orifice.  Upper 
part  of  line  corresponds  to  left  auriculo-ventricular  orifice,  mitral  valve. 
Lower  part  of  line  corresponds  to  right  auriculo-ventricular  opening,  tri- 
cuspid valve.  Position  of  the  diaphragm  is  indicated  by  the  curved  line  that 
passes  below  the  inferior  border  of  the  heart. 

placed  upon  the  junction  of  the  third  costal  cartilage  with  the  left 
border  of  the  sternum,  half  of  the  line  upon  the  cartilage  and  half 
upon  the  sternum. 

The  aortic  orifice,  valve,  may  be  indicated  by  a  line  drawn  from 


MEDIASTINUM  AND  CONTENTS.  195 

the  junction  of  the  third  costal  cartilage  with  the  left  border  of  the 
sternum,  just  below  the  line  indicating  the  pulmonary  valve  and 
diverging  from  this,  as  far  as  the  middle  line,  to  a  level  with  the 
third  space. 

The  auriculo-ventricular  openings  are  represented  by  a  line  ex- 
tending from  the  lower  border  of  the  third  left  costal  cartilage,  one 
finger's  breadth  beyond  the  left  border  of  the  sternum,  downward 
and  toward  the  right,  across  the  body  of  the  sternum,  as  far  as  the 
junction  of  the  sixth  right  costal  cartilage  with  the  right  border  of 
the  sternum.  The  lower  part  of  this  line  represents  the  tricuspid 
(right  auriculo-ventricular)  orifice  and  the  upper  part  represents  the 
mitral  (left  auriculo-ventricular)  orifice. 

The  Thymus. — The  thymus  body  in  the  newborn  is  located  in 
the  upper  front  part  of  the  mediastinum  behind  the  sternum  and 
in  front  of  the  upper  part  of  the  pericardial  sac.  Its  upper  portion 
reaches  well  upward,  in  front  of  the  trachea,  into  the  root  of  the 
neck.  In  the  upper  part  of  the  mediastinal  space  the  thymus  lies 
directly  in  front  of  the  trachea,  the  left  innominate  vein,  which 
passes  from  left  to  right,  across  the  front  of  the  trachea,  being  in- 
terposed between  them.  In  the  root  of  the  neck  the  thymus  lies 
upon  the  front  of  the  trachea,  and  is  in  relation,  on  either  side,  with 
the  common  carotid  artery  and  the  internal  jugular  vein. 

The  lower  part  of  the  thymus  lies  behind  the  body  of  the  ster- 
num and  in  front  of  the  great  vessels  at  the  base  of  the  heart,  dip- 
ping down  between  the  pericardial  sac  and  the  edges  of  the  lungs 
and  pleura. 

The  thymus  increases  in  size  from  birth  until  the  second  year, 
and  then  remains  stationary  or  atrophies  slowly  until  puberty.  After 
puberty  it  atrophies  rapidly,  undergoing  fatty  changes. 

The  Arch  of  the  Aorta.  —  The  arch  of  the  aorta  is  well  sur- 
rounded by  the  lungs,  the  edges  of  which  nearly  meet  behind  the 
sternum. 

It  arises  from  the  left  ventricle,  and  at  its  origin  lies  behind 
the  root  of  the  pulmonary  artery.  It  first  passes  upward,  forward, 
and  toward  the  right  as  far  as  the  right  border  of  the  sternum;  it 
then  turns  backward  and  toward  the  left,  arching  over  the  left  bron- 
chus; and  near  the  upper  border  of  the  body  of  the  fourth  dorsal 
vertebra,  upon  its  left  side,  it  turns  downward  and  is  continued  as 
the  thoracic  aorta. 

The  arch,  as  it  passes  backward  and  to  the  left  over  the  left 


196  THORAX. 

bronchus,  reaches  its  highest  point,  which  is  upon  a  level  with  the 
upper  border  of  the  first  costal  cartilage. 

The  Ascending  Paet  of  the  Arch. — Upon  the  right  side  and 
close  to  the  ascending  or  first  part  of  the  arch  lies  the  superior  vena 
cava,  which  enters  the  upper  part  of  the  right  auricle;  this  part  of 
the  arch  and  the  superior  vena  cava  are  situated  in  front  of  the  root 
of  the  right  lung.  The  vena  azygos,  passing  forward  from  the  right 
side  of  the  vertebral  column,  crosses  the  root  of  the  right  lung  and 
empties  into  the  vena  cava  superior  through  its  posterior  wall. 

The  Transverse  Part  of  the  Arch. — The  transverse  part  of 
the  arch  passes  from  right  to  left  and  from  before  backward,  from 
the  right  border  of  the  sternum  to  the  left  side  of  the  body  of  the 
fourth  dorsal  vertebra,  arehing  over  the  root  of  the  left  lung.  Its 
upper  border  is  upon  a  level  with  the  upper  border  of  the  first  costal 
cartilage.  From  the  upper  aspect  of  the  transverse  part  of  the  arch 
are  given  off  the  innominate  and  the  left  common  carotid  and  sub- 
clavian arteries. 

Below  the  transverse  part  of  the  arch  is  the  pulmonary  artery 
and  its  bifurcation,  the  branches  passing  transversely — one  to  the 
hilum  of  each  lung — and  lying  in  front  of  the  bronchi.  Behind  the 
transverse  part  of  the  arch,  in  the  back  part  of  the  mediastinum, 
the  trachea  and  the  oesophagus  are  located. 

In  front  of  the  transverse  part  of  the  arch  are  the  sternum, 
the  thymus  or  its  remains,  and  the  edges  of  the  pleura  and  the  edges 
of  the  lungs,  which  nearly  meet  directly  behind  the  sternum.  A 
little  above  and  in  front  of  the  transverse  part  of  the  arch,  passing 
from  left  to  right  across  the  middle  line,  is  the  left  innominate  vein. 
The  left  superior  intercostal  vein  passes  forward  from  the  third  left 
intercostal  space  near  the  spinal  column  and  enters  the  left  innomi- 
nate in  front  of  this  part  of  the  arch.  To  the  left  of  the  middle  line, 
the  left  pneumogastric  nerve  descends  in  front  of  and  close  to  the 
transverse  part  of  the  arch,  and  gives  off  its  recurrent  laryngeal 
branch,  which  curves  around  the  arch  and  ascends  into  the  neck. 
Also  descending  in  front  of  the  transverse  part  of  the  arch,  but 
nearer  the  middle  line  than  the  left  pneumogastric,  is  the  left 
phrenic  nerve. 

The  Pneumogastric  Nerves. — These  pass  through  the  thoracic 
cavity,  in  close  relation  with  the  oesophagus,  on  their  way  to  the 
stomach. 

The  right  pneumogastric,  at  the  root  of  the  neck,  lies  between 


MEDIASTINUM  AND  CONTENTS.  197 

the  common  carotid  artery  and  the  internal  jugular  vein.  It  de- 
scends into  the  chest,  across  the  front  of  the  first  part  of  the  sub- 
clavian artery,  between  it  and  the  subclavian  vein.  Within  the  chest 
it  passes  obliquely  backward,  close  to  the  right  side  of  the  trachea 
and  across  the  posterior  aspect  of  the  root  of  the  right  lung,  where 
it  takes  part  in  the  formation  of  the  posterior  pulmonary  plexus. 
The  nerve  then  approaches  the  middle  line  and  descends  upon  the 
posterior  surface  of  the  oesophagus  and  through  the  oesophageal 
opening  in  the  diaphragm,  to  be  distributed  to  the  posterior  sur- 
face of  the  stomach. 

The  left  pneumogastric  dips  into  the  chest  between  the  left 
carotid  and  subclavian  arteries,  behind  the  left  innominate  vein,  and, 
descending  across  the  front  of  the  left  end  of  the  transverse  part 
of  the  arch  of  the  aorta,  is  continued  downward,  behind  the  root  of 
the  left  lung  and  thence  upon  the  front  surface  of  the  oesophagus 
and  through  the  diaphragm,  to  be  distributed  to  the  anterior  surface 
of  the  stomach. 

The  Inferior  Recurrent  Branches.  —  Upon  the  right  side 
the  inferior  recurrent  is  given  off  from  the  pneumogastric  as  it 
passes  across  the  front  of  the  first  part  of  the  subclavian  artery. 
Curving  around  this  vessel,  it  ascends  in  the  neck,  in  the  recess  be- 
tween the  oesophagus  and  the  trachea,  to  enter  the  lower  part  of  the 
larynx. 

Upon  the  left  side  the  recurrent  is  given  off  as  the  pneumo- 
gastric passes  across  the  front  of  the  transverse  part  of  the  arch  of 
the  aorta.  It  winds  around  the  lower  border  of  this  part  of  the 
arch  and  ascends  in  the  neck,  having  a  similar  relation  to  the  oesoph- 
agus and  trachea  as  that  of  the  right  side. 

The  Phrenic  Nerves. — In  the  root  of  the  neck  the  phrenic  nerve 
of  either  side  may  be  seen  crossing  the  front  of  the  scalenus  anticus 
tendon  in  a  direction  from  above  downward  and  inward.  After  en- 
tering the  chest  they  pass  down  in  front  of  the  root  of  either  lung; 
the  left,  in  its  course,  passes  across  the  front  of  the  transverse  part 
of  the  arch  of  the  aorta  parallel  with  the  left  pneumogastric,  but 
more  internally,  nearer  the  middle  line;  the  right  passes  down  upon 
the  right  side  of  the  superior  vena  cava.  They  then  descend  between 
the  pericardium  and  the  mediastinal  portion  of  the  pleura  as  far  as 
the  diaphragm,  which  they  supply. 

The  Trachea. — This  is  an  elastic  membranous  tube  which  is  put 
upon  the  stretch  when  the  head  is  extended.     Set  into  its  wall  are 


198  THORAX. 

a  number  of  cartilaginous  plates,  each  forming  part  of  a  circle. 
These  cartilaginous  plates  are  absent  in  the  posterior  part  of  the 
trachea. 

The  trachea  is  the  continuation  of  the  larynx.  It  begins  in 
the  neck  below  the  cricoid  cartilage  at  the  sixth  cervical  vertebra, 
and  in  this  part  of  its  course  lies  quite  superficial.  As  it  passes 
downward  it  gets  to  lie  deeper,  farther  away  from  the  surface.  In 
the  chest,  opposite  the  fifth  dorsal  vertebra,  just  above  the  base  of 
the  heart,  the  trachea  divides  into  the  two  bronchi. 

In  front  of  the  trachea,  in  the  upper  part  of  the  mediastinum, 
are  the  sternum,  the  thymus  or  its  remains,  connective  tissue,  and 
fat.  It  is  crossed  from  left  to  right  and  obliquely  from  above  down- 
ward by  the  left  innominate  vein;  into  this  vein  in  front  of  the 
trachea,  one  on  each  side  of  the  middle  line,  empty  the  inferior  thy- 
roid veins.1  Occasionally  a  large  arterial  branch,  the  thyroidea  ima, 
arises  from  the  upper  aspect  of  the  transverse  part  of  the  arch  of 
the  aorta  and  ascends  upon  the  front  of  the  trachea.  Lower  down, 
the  trachea  is  crossed  by  the  transverse  part  of  the  arch  of  the  aorta 
and  the  vessels  arising  from  the  superior  aspect  of  this  vessel.  The 
innominate  and  left  carotid  arteries,  at  their  origin,  are  placed  in 
front  of  the  trachea.  The  right  pneumogastric,  in  the  upper  part 
of  the  chest,  lies  close  to  the  right  side  of  the  trachea.  The  oesoph- 
agus is  situated  behind  the  trachea.  It  is  intimately  related  to  the 
posterior,  non-cartilaginous  wall  of  the  trachea;  so  that  foreign 
bodies  lodged  in  the  oesophagus  may,  by  pressure  upon  the  posterior 
wall  of  the  trachea,  seriously  narrow  its  lumen  and  produce  symp- 
toms of  strangulation.  In  the  immediate  neighborhood  of  the  bifur- 
cation of  the  trachea  are  twenty  to  thirty  lymphatic  nodes. 

The  (Esophagus.  —  The  oesophagus  is  the  continuation  of  the 
pharynx,  and  consists  of  a  thick  muscular  coat  with  a  mucous  mem- 
brane lining.  The  mucous  membrane  is  connected  with  the  mus- 
cular coat  by  a  very  loose  submucous  connective  tissue. 

When  collapsed,  the  oesophagus  appears  as  a  flat,  transverse 
band,  with  the  mucous  membrane  thrown  into  longitudinal  folds, 
and  upon  cross  section  it  shows  a  stellate  figure. 

The  oesophagus  commences  behind  the  cricoid  cartilage  on  a 
level  with  the  sixth  cervical  vertebra;  it  descends  through  the  neck 
and  thorax,  piercing  the  diaphragm  upon  a  level  with  the  tenth 


1  The  right  inferior  thyroid  often  empties  into  the  right  innominate. 


MEDIASTINUM  AND  CONTENTS.  199 

dorsal  vertebra",  and  terminates  at  the  cardiac  end  of  the  stomach 
upon  a  level  with  the  eleventh  dorsal  vertebra. 

In  the  neck  and  upper  part  of  the  thorax,  as  far  as  the  fourth 
dorsal  vertebra,  the  oesophagus  lies  close  to  the  front  of  the  vertebral 
column,  but  from  this  point  downward  it  gets  to  lie  farther  away, 
and  as  it  passes  through  the  diaphragm  it  is  located  quite  some  dis- 
tance in  front  of  and  to  the  left  of  the  tenth  dorsal  vertebra. 

The  oesophagus,  throughout  its  course,  is  surrounded  by  loose, 
cellular  tissue  by  which  it  is  connected  with  adjoining  structures. 
The  average  length  of  the  oesophagus  is  about  35  cm.,  and  the  dis- 
tance from  the  teeth  to  the  cardiac  orifice  of  the  stomach  is  about 
50  cm.  To  get  the  distance  from  the  mouth  to  the  cardiac  orifice 
of  the  stomach,  in  any  individual  case,  one  may  measure  from  the 
spinous  process  of  the  eleventh  dorsal  vertebra  to  that  of  the  ver- 
tebra prominens,  and  thence  across  the  shoulder  to  the  mouth. 

The  lumen  of  the  oesophagus  is  narrowest  at  its  commencement 
behind  the  cricoid  cartilage,  again  narrow  opposite  the  third  or 
fourth  dorsal  vertebra  and  again  as  it  passes  through  the  diaphragm. 
At  its  narrowest  part  the  caliber  of  the  oesophagus  has  a  diameter 
of  14  mm.,  but  it  is  capable  of  much  distension  beyond  this. 

Eelations  of  the  (Esophagus.  In  the  Neck  the  oesophagus  lies 
upon  the  front  of  the  spinal  column  and  immediately  behind  the 
trachea,  to  the  posterior  non-cartilaginous  wall  of  which  it  is  united 
by  loose  connective  tissue.  The  oesophagus,  situated  behind  the 
trachea,  protrudes  a  considerable  distance  beyond  the  left  border  of 
the  latter,  and  is  therefore  in  closer  relation  with  the  common 
carotid  artery,  internal  jugular  vein,  etc.,  upon  the  left  side  of  the 
neck  than  upon  the  right  side.  In  the  recess  between  the  trachea 
in  front  and  the  oesophagus  behind,  upon  either  side,  the  recurrent 
laryngeal  nerve  ascends  to  enter  the  lower  part  of  the  larynx.  Above, 
where  the  lateral  lobes  of  the  thyroid  gland  rest  upon  the  sides  of 
the  trachea,  they  reach  backward  so  as  to  get  into  close  proximity 
with  the  oesophagus. 

Within  the  Chest. — In  the  upper  part  of  the  chest  the  oesophagus 
is  still  situated  in  front  of  the  spinal  column  close  behind  the  trachea, 
protruding  somewhat  beyond  the  left  border  of  the  latter.  Opposite 
the  third  dorsal  vertebra  it  is  placed,  together  with  the  trachea,  be- 
hind the  transverse  part  of  the  arch  of  the  aorta.  Opposite  the 
fourth  dorsal  vertebra  the  descending  part  of  the  arch  of  the  aorta 
lies  to  the  left  side  of  the  oesophagus,  pushing  it  (the  oesophagus)  a 


200  THORAX. 

little  over  toward  the  right;  but  immediately  below  this  the  azygos 
vein,  appearing  upon  the  right  side  of  the  oesophagus,  forces  it  again 
to  the  left,  and  here  at  this  level  the  oesophagus  is  found  behind  the 
root  of  the  left  lung,  to  which  it  is  loosely  attached  by  connective 
tissue.  As  the  oesophagus  descends  it  remains  in  close  relation  with 
the  aorta,  which  vessel  gradually  passes  behind  it  in  order  to  reach 
the  middle  line  in  front  of  the  vertebral  column.  Opposite  the  eighth 
dorsal  vertebra  the  oesophagus  lies  in  front  of  the  aorta,  and  opposite 
the  tenth,  as  it  pierces  the  diaphragm  to  terminate  in  the  stomach, 
it  lies  in  front  and  to  the  left  of  the  aorta  and  spinal  column. 

In  the  space  behind  the  heart,  between  it  and  the  vertebral 
column,  in  the  lower  back  part  of  the  mediastinum,  the  oesophagus 
lies  in  close  proximity,  anteriorly,  with  the  left  auricle,  which  is 
enveloped  in  the  pericardial  sac.  In  this  space,  upon  the  right  side 
of  the  vertebral  column,  is  the  azygos  vein;  upon  the  left,  the 
hemiazygos;  and  in  front  of  the  vertebral  column,  the  thoracic  duct; 
the  aorta  is  situated  behind  the  oesophagus.  The  mediastinal  portion 
of  the  pleura,  as  it  passes  forward  to  the  root  of  the  lung,  is  reflected 
upon  either  side  of  the  oesophagus.  Descending  upon  the  anterior 
wall  of  the  oesophagus  is  the  left  pneumogastric,  and,  upon  its  poste- 
rior wall,  the  right  pneumogastric  nerve.  These  nerves  accompany 
the  oesophagus  through  the  oesophageal  opening  in  the  diaphragm 
and  are  distributed  to  the  stomach. 

The  Thoracic  Aorta. — This  is  the  continuation  of  the  arch.  It 
lies  at  first  upon  the  left  side  of  the  bodies  of  vertebrae,  but  as  it 
descends  it  approaches  the  middle  line,  and  finally,  as  it  passes  into 
the  abdomen  behind  the  diaphragm,  it  lies  in  front  of  the  body  of 
the  last  dorsal  vertebra.  Throughout  its  course  the  thoracic  aorta 
is  closely  related  to  the  oesophagus;  at  first  it  lies  to  the  left  side 
of  the  oesophagus,  but  as  it  descends  it  gets  behind  it,  between  it  and 
the  vertebral  column;  below,  the  oesophagus  is  placed  in  front  of 
and  to  the  left  of  the  aorta,  the  latter  (aorta)  as  it  passes  into  the 
abdomen  being  situated  upon  the  front  of  the  spinal  column.  The 
thoracic  aorta  gives  off  the  intercostal  branches:  one  for  each  inter- 
costal space  from  the  third  downward. 

The  Vena  Azygos. — This  vein  ascends  upon  the  right  side  of  the 
spinal  column;  it  is  made  up  of  branches  from  the  lumbar  region 
and  receives  the  intercostals  in  its  course.  About  the  level  of  the 
fourth  dorsal  vertebra  it  passes  forward  over  the  root  of  the  right 
lung,  and  enters  the  vena  cava  superior  through  its  posterior  wall. 


PLEURA.  201 

The  Vena  Hemiazygos. — The  origin  and  course  of  this  vessel 
are  analogous  to  those  of  the  azygos.  It  ascends  upon  the  left  side 
of  the  vertebral  column.  Opposite  the  eighth  dorsal  vertebra  it 
passes  across  the  front  of  the  spinal  column  behind  the  aorta  and 
thoracic  duct,  and  upon  the  right  side  of  the  vertebral  column  joins 
the  vena  azygos. 

The  Thoracic  Duct  passes  into  the  thorax  behind  the  diaphragm 
in  company  with  the  aorta,  between  this  vessel  and  the  front  of  the 
spinal  column.  As  it  ascends  through  the  thorax  it  lies  upon  the 
bodies  of  the  dorsal  vertebrae.  In  the  upper  part  of  the  chest  it 
arches  forward  and  outward  toward  the  left,  and,  passing  over  the 
subclavian  artery  and  across  the  front  of  the  tendon  of  the  scalenus 
anticus,  it  enters  the  left  subclavian  vein  where  this  vessel  joins  the 
left  internal  jugular. 

The  Innominate  Artery  has  a  caliber  corresponding  to  the  thick- 
ness of  the  little  finger.  It  springs  from  the  right  end  of  the  upper 
border  of  the  transverse  part  of  the  arch  of  the  aorta,  and  is  about 
5  cm.  long.  At  its  origin  it  lies  in  front  of  the  trachea;  it  terminates 
by  dividing  into  the  subclavian  and  common  carotid  behind  the 
right  sterno-clavicular  joint. 

Situated  in  front  of  this  vessel  are  the  sternal  attachments  of 
the  sterno-hyoid  and  sterno-thyroid  muscles,  the  manubrium  of  the 
sternum,  and  the  remains  of  the  thymus  gland.  The  left  innominate 
vein  passes  across  the  front  of  the  root  of  the  innominate  artery,  and 
upon  its  outer  (right)  side  joins  with  the  right  innominate  vein  to 
form  the  vena  cava  superior.  The  right  inferior  thyroid  vein,  as  it 
descends  from  the  lower  part  of  the  thyroid  gland  to  enter  the  right 
innominate  vein,  also  passes  across  the  front  of  the  innominate 
artery.  To  the  outer  side  of  the  innominate  artery  lie  the  right  pneu- 
mogastric  and  the  right  phrenic  nerves  and  the  pleura  and  apex  of 
the  right  lung.  To  the  inner  side  of  the  innominate  is  the  left 
common  carotid,  the  distance  between  the  two  vessels  varying. 

The  Left  Common  Carotid  and  Left  Subclavian  Arteries  arise 
from  the  upper  border  of  the  transverse  part  of  the  arch.  They  lie 
deep  within  the  chest,  and  are,  in  this  region,  not  subject  to  surgical 
interference. 

THE  PLEURA. 

The  pleura  of  each  side  is  a  completely  closed  fibro-serous  sac. 
It  lines  the  entire  inner  surface  of  the  cavity,  within  which  the  lung 


202  THORAX. 

is  contained,  and,  besides,  as  a  thin,  serous  layer,  invests  the  whole 
surface  of  the  lung. 

That  portion  of  the  pleura  which  is  applied  to  the  surface  of 
the  lung  is  called  the  visceral  layer,  and  that  which  lines  the  whole 
inner  surface  of  the  cavity  in  which  the  lung  is  contained  is  called 
the  parietal  layer.  That  part  of  the  parietal  pleura  which  lines  the 
inner  surface  of  the  wall  of  the  chest,  sternum,  costal  cartilage,  ribs, 
etc.,  is  spoken  of  as  the  pleura  sterno-costalis;  that  portion  which 
is  spread  out  upon  the  surface  of  the  diaphragm,  the  pleura  dia- 
phragmatica;  and  that  which  limits  the  mediastinum  on  each  side, 
passing  from  before  backward  like  a  partition  and  separating  the 
mediastinal  space  from  the  space  which  contains  the  lung,  is  called 
the  pleura  mediastinalis. 

The  parietal  layer,  after  lining  the  inner  surface  of  the  ribs, 
intercostal  muscles,  etc., — that  is,  the  whole  inner  aspect  of  the 
wall  of  the  thorax, — is  found,  behind,  upon  either  side  of  the  verte- 
bral column,  to  leave  the  posterior  wall  of  the  thorax  and  pass 
forward,  forming  the  posterior  part  of  the  mediastinal  pleura;  that 
of  the  left  side,  as  it  passes  forward,  covers  the  adjacent  wall  of 
the  aorta  and,  lower  down,  the  oesophagus;  that  of  the  right  side, 
as  it  passes  forward,  covers,  below,  the  side  of  the  vena  azygos  and, 
higher  up,  the  side  of  the  oesophagus.  Upon  reaching  the  posterior 
aspect  of  the  root  of  the  lung  the  pleura  is  reflected  on  to  the  sur- 
face of  the  lung  and  as  the  visceral  layer  completely  invests  it,  being 
also  continued  in  between  the  lobes  and  intimately  united  with  its 
surface;  after  thus  entirely  enveloping  the  lung  it  reaches  the  ante- 
rior aspect  of  the  root  of  the  lung,  whence  it  is  reflected  forward 
toward  the  sternum  as  the  anterior  portion  of  the  mediastinal  pleura; 
upon  reaching  the  posterior  surface  of  the  sternum  it  becomes  con- 
tinuous with  that  part  of  the  parietal  pleura  which  lines  the  inner 
surface  of  the  wall  of  the  chest:  the  pleura  sterno-costalis.  Above 
and  below  the  level  of  the  root  of  the  lung  the  mediastinal  pleura 
passes  all  the  way  as  an  uninterrupted  layer  from  behind  forward, 
from  either  side  of  the  spinal  column  to  the  posterior  surface  of  the 
sternum. 

Limits  of  the  Pleura  as  Indicated  by  Lines  upon  the  Chest  Wall. 
The  Anteriok  Edge  of  the  Pleura. — The  line  which  indicates 
the  anterior  edge  of  the  right  pleural  sac  commences,  above,  behind 
the  right  sterno-clavicular  articulation;  from  this  point  it  passes 
downward  and  inward  behind  the  sternum,  and  at  the  junction  of 


-Fig.  S4.— Outline  of  Pleura,  etc.  Front  view.  ^4.,  apex  of  lung  and  dome 
of  pleura;  D,  line  of  diaphragm;  H,  outline  of  heart;  L,  solid  lines  show  the 
edges  of  the  lungs;  P,  dotted  lines  correspond  to  the  edges  of  the  pleura. 


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PLEURA.  203 

the  manubrium  with,  the  body  of  the  sternum  it  lies  close  to  the 
middle  line;  it  is  then  continued  downward  behind  the  middle  of 
the  body  of  the  sternum,  and  opposite  the  articulation  of  the  fourth 
costal  cartilage  it  curves  outward,  as  it  descends,  to  reach  a  point 
corresponding  to  the  lower  border  of  the  sternal  end  of  the  sixth 
costal  cartilage,  whence  it  may  be  traced  farther  downward  and 
backward  as  the  lower  edge  of  the  pleura. 

The  line  which  marks  the  anterior  edge  of  the  left  pleural  sac 
is  somewhat  different.  It  commences  above,  behind  the  left  sterno- 
clavicular articulation,  from  which  point  it  curves  downward  and 
inward  toward  the  middle  line  and  may  then  be  traced  downward 
behind  the  body  of  the  sternum  parallel  with  the  anterior  edge  of 
the  right  pleural  sac  to  a  point  upon  a  level  with  the  junction  of  the 
fourth  costal  cartilage  with  the  sternum;  here  it  curves  outward, 
but  more  obliquely  than  upon  the  right  side,  and  reaches  the  sternal 
end  of  the  sixth  costal  cartilage  at  its  upper  border,  whence  it  is  con- 
tinued obliquely  downward  and  backward  as  the  lower  edge  of  the 
pleura. 

According  to  Alerkel,  the  anterior  edge  of  the  left  pleural  sac, 
upon  a  level  with  the  fourth  costal  cartilage,  passes  still  more 
obliquely  outward  than  has  been  described  above  so  as  to  strike  the 
sixth  costal  cartilage,  not  at  its  junction  with  the  sternum,  but  some 
little  distance  beyond  this  articulation,  thus  leaving  a  space  between 
the  anterior  edge  of  the  left  pleural  sac  and  the  left  border  of  the 
sternum,  corresponding  to  the  fifth  costal  cartilage,  fifth  intercostal 
space,  and  sixth  costal  cartilage,  which  is  not  covered  by  the  pleura. 
If  this  condition  were  present,  one  might  introduce  an  aspirating 
needle  into  the  pericardial  sac  through  the  fifth  intercostal  space, 
close  to  the  left  border  of  the  sternum,  without  encountering  the 
pleura. 

"Without  doubt  the  anterior  edge  of  the  left  pleural  sac  is  sub- 
ject to  considerable  variation.  I  have  found  the  first  description  to 
hold  for  most  cases. 

The  Lowee  Edge  oe  the  Pleuea  corresponds  to  a  line  that 
commences,  in  front,  behind  the  junction  of  the  sixth  costal  carti- 
lage with  the  sternum;  it  passes  downward  and  backward,  crossing 
obliquely  the  cartilage  of  the  seventh  rib  in  the  parasternal  line  and 
passing  into  the  seventh  intercostal  space  in  the  mammary  line;  still 
continued  downward  and  backward  it  reaches  its  deepest  point,  cor- 
responding to  the  tenth  rib  or  tenth  intercostal  space,  a  little  behind 


204 


THORAX. 


the  axillary  line,  whence  it  may  be  traced  almost  horizontally  back- 
ward and  inward  to  the  articulation  of  the  twelfth  rib  with  the 
spinal  column.  Behind,  in  the  scapular  line,  the  lower  edge  of  the 
pleura  corresponds  to  the  tenth  intercostal  space. 

It  will  be  observed  that  the  lower  edge  of  the  pleura,  as  it  is 
reflected  from  the  inner  surface  of  the  chest  wall  over  on  to  the 
surface  of  the  diaphragm,  does  not  dip  down  into  the  bottom  of  the 
recess  between  the  costal  portion  of  the  diaphragm  and  the  ribs. 
This  space  varies  in  depth  at  different  parts.     Occasionally  the  lower 


Fig.  87.— Section  through  Seventh,  Eighth,  and  Ninth  Ribs  Anterior  to 
the  Axillary  Line.  D,  diaphragm;  EX,  external  intercostal  muscle;  IN,  in- 
ternal intercostal  muscle;  P,  pleura  covering  inner  aspect  of  the  chest  wall; 
PI),  pleura  that  covers  the  diaphragm;  PE,  peritoneum  that  is  reflected  upon 
the  under  surface  of  the  diaphragm;  VAN,  intercostal  vein,  artery,  and  nerve 
situated  under  lower  border  of  the  ribs;  7,  8,  9,  cut  surface  of  ribs;  *  repre- 
sents the  space  between  the  diaphragm  and  chest  wall  into  which  the  pleura 
does  not  descend,  as  it  is  reflected  from  the  chest  wall  on  to  the  upper  sur- 
face of  the  diaphragm. 

edge  of  the  pleura,  behind,  reaches  down  between  the  twelfth  rib  and 
the  diaphragm  as  far  as  the  lower  border  of  the  twelfth  rib,  or,  even 
beyond  this,  down  to  the  level  of  the  transverse  process  of  the  first 
lumbar  vertebra. 

The  Dome  of  the  pleura  is  that  part  of  the  pleural  sac  which 
projects  upward  into  the  root  of  the  neck  above  the  level  of  the  first 
rib;  it  reaches  to  a  distance  of  5  cm.  above  the  level  of  the  anterior 
part  of  the  first  rib,  but  does  not  reach  above  the  level  of  the  back 
part  of  the  first  rib;  the  first  rib  is  set  very  obliquely,  its  anterior 
portion  being  upon  a  much  lower  level  than  its  posterior  part. 


LUNGS.  205 

The  dome  Of  the  pleura  reaches  from  2  to  4  cm.  above  the  level 
of  the  clavicle;  so  that  a  knife  introduced  above  this  bone  and  passed 
directly  backward  would  pierce  both  the  pleura  and  the  lung.  In 
front  of  the  dome  is  the  first  rib  and  the  posterior  surface  of  the 
scalenus  anticus  muscle  and  the  clavicle.  Internal  to  the  dome  are 
the  trachea  and  the  oesophagus. 

The  subclavian  vessels  pass  forward  and  outward  across  the 
dome,  grooving  it  and  the  apex  of  the  lung,  which  lies  beneath.  Care 
is  necessary  in  ligating  the  subclavian  or  innominate  arteries  not  to 
wound  the  pleura. 

As  the  internal  mammary  artery  dips  down  into  the  chest  it  is 
crossed  by  the  phrenic  nerve  and  lies  in  close  relation  with  the  dome 
of  the  pleura. 

The  dome  of  the  pleura  is  re-enforced  by  the  fascia  endotho- 
racica,  and  connected  behind,  through  ligamentous  bands,  with  the 
first  rib  and  the  last  cervical  and  the  first  dorsal  vertebras  and  in 
front  with  the  deep  surface  of  the  scaleni  muscles. 

The  mediastinal  portion  of  the  pleura  and  the  pericardium  are 
adherent  to  each  other,  and  between  these  two  serous  layers  the 
phrenic  nerves  descend  to  the  diaphragm. 


THE  LUNGS. 

The  Root,  or  Pedicle,  of  the  Lung. — The  root  of  the  lung  is 
located  in  the  back  part  of  the  mediastinum  behind  the  ascending 
part  of  the  arch  of  the  aorta  and  above  the  base  of  the  heart.  That 
of  each  lung  is  composed  of  the  bronchus,  the  pulmonary  artery,  and 
the  pulmonary  veins,  together  with  lymphatics  (also  blood-vessels  for 
the  supply  of  lung  tissue  proper  and  plexuses  of  nerves). 

The  trachea  bifurcates  opposite  the  fifth  dorsal  vertebra,  and 
its  divisions,  the  bronchi,  are  directed  outward  and  downward  toward 
the  hilum  of  either  lung.  The  right  bronchus  is  more  horizontal, 
shorter,  and  of  wider  caliber  than  the  left,  and  its  lumen  is  more 
directly  continuous  with  that  of  the  trachea;  so  that  foreign  bodies 
dropped  into  the  trachea  are  more  apt  to  enter  the  right  than  the 
left  bronchus. 

The  pulmonary  artery  springs  from  the  upper  part  of  the  right 
ventricle,  and  at  its  origin  lies  in  front  of  the  root  of  the  aorta.  It  is 
a  short  trunk,  directed  upward  and  backward,  and  under  the  trans- 


206  THORAX. 

verse  part  of  the  arch  of  the  aorta  divides  into  the  right  and  left 
pulmonary.  These  pass  outward,  in  front  of  the  bronchi,  to  the  hilum 
of  either  lung.  At  the  hilum  the  pulmonary  arteries  are  located  upon 
a  higher  level  than  the  bronchi,  and  may  get  to  lie  partly  behind 
these'  as  they  enter  the  lung. 

The  pulmonary  veins  are  short  trunks  which,  upon  leaving  the 
hilum  of  the  lung,  pass  transversely  inward  and  enter  the  correspond- 
ing side  of  the  left  auricle;  they  lie  some  little  distance  below  the 
level  of  the  bronchi  and  the  pulmonary  arteries. 

There  are  numerous  lymph  nodes  irregularly  arranged  about 
the  root  of  the  lung,  but  there  is  always  a  well-marked  group  below 
the  bifurcation  of  the  trachea. 

Over  the  root  of  the  left  lung,  arching  from  before  backward, 
is  the  arch  of  the  aorta.  The  vena  azygos  passes  over  the  root  of 
the  right  lung,  from  behind  forward,  and  enters  the  vena  cava  supe- 
rior, which  lies  just  in  front  of  the  root  of  the  right  lung,  upon  its 
posterior  aspect. 

The  Lung,  suspended  by  its  root,  occupies  the  pleural  cavity 
and  is  entirely  enveloped  by  the  visceral  layer  of  the  pleura.  At  the 
root  of  the  lung  this  visceral  layer  of  the  pleura  is  continuous  with 
the  mediastinal  part  of  the  parietal  pleura.  The  base  of  the  lung 
rests  upon  the  diaphragm;  its  apex  projects  into  the  root  of  the 
neck  for  a  distance  of  4  or  5  cm.  above  the  front  end  of  the  first 
rib.  In  the  natural  sitting  position  the  apex  of  the  lung  reaches  to 
a  point  about  3  cm.  above  the  clavicle. 

The  right  lung  consists  of  three  lobes,  the  left  of  two.  Each 
lung  upon  its  inner  surface  shows  a  depression  corresponding  to  the 
heart,  that  upon  the  left  lung  being  deeper  than  that  upon  the  right 
lung. 

The  lung  does  not  entirely  fill  the  pleural  cavity  except  above, 
where  the  apex  occupies  all  the  space  corresponding  to  the  dome  of 
the  pleura. 

Limits  of  the  Lungs. — The  posterior  border  of  each  lung  is 
found  alongside  the  vertebral  column.  The  anterior  border  of  the 
lung  corresponds  to  the  line  of  the  pleura  from  the  sterno-clavicular 
articulation  to  the  level  of  the  fourth  costal  cartilage.  The  anterior 
border  of  the  right  lung  continues  to  be  the  same  as  that  of  the  pleura 
down  to  the  level  of  the  sixth  costal  cartilage.  The  anterior  border 
of  the  left  lung,  at  the  junction  of  the  fourth  costal  cartilage  with 
the  sternum,  passes  almost  transversely  outward  behind  the  cartilage 


OPERATIONS  UPON"  THE  THORAX.  207 

of  the  fourth  rib,  forming  the  upper  border  of  the  incisura  cardiaca, 
and  then,  midway  between  the  border  of  the  sternum  and  the  nipple, 
it  turns  downward  behind  the  fourth  intercostal  space  and  fifth  costal 
cartilage,  and  in  the  fifth  space  passes  sharply  inward,  forming  the 
lower  border  of  the  incisura  cardiaca. 

The  lower  border  of  either  lung  is  represented  by  a  line  which 
commences  at  the  junction  of  the  sixth  costal  cartilage  with  the 
sternum;  it  passes  downward  and  backward,  behind  the  sixth  costal 
cartilage,  and  crosses  the  seventh  rib  in  the  mammary  line;  from 
this  point  the  line  passes  backward,  almost  transversely,  crossing  the 
eighth  and  ninth  ribs  in  the  axillary  line,  the  tenth  rib  in  the  scap- 
ular line,  and  reaches  the  vertebral  column  upon  a  level  with  the 
articulation  of  the  eleventh 'rib.  Although  the  line,  after  crossing 
the  seventh  rib  in  the  mammary  line,  is  continued  almost  trans- 
versely backward,  it  cuts  the  eighth,  ninth,  and  succeeding  lower 
ribs,  owing  to  the  obliquity  of  the  ribs. 

The  lower  edge  of  the  lung  does  not  reach  to  the  bottom  of 
the  pleural  cavity;  so  that  a  space  is  left  which  is  called  the  sinus 
phrenico-costalis.  This  space  commences  in  front,  and  gradually 
becomes  deeper;  upon  the  sides  it  is  deepest,  and  may  measure  up 
to  two  inches.  In  more  forcible  inspiration  this  space  is  partly 
obliterated  by  the  increased  expansion  of  the  lung. 

A  similar  pleural  space,  unoccupied  by  the  lung  (incisura  car- 
diaca), is  found  in  front  of  the  pericardium  and  heart,  corresponding 
to  the  fourth  intercostal  space  and  fifth  costal  cartilage,  to  the  left 
of  the  sternum. 

In  the  child  the  distance  between  the  lower  border  of  the  lung 
and  the  bottom  of  the  pleural  cavity  is  one-half  to  one  space  deeper 
than  described  above.  In  old  age  the  distance  between  the  lower 
border  of  the  lung  and  the  bottom  of  the  pleural  cavity  becomes 
one-half  to  one  space  shorter. 

Luschka  gives  the  depth  of  the  sinus  phrenico-costalis  as  fol- 
lows: In  the  sternal,  parasternal,  and  mammary  lines,  2  cm.;  in  the 
axillary  line,  6  cm.;  and  near  the  vertebra,  2.5  cm. 

OPERATIONS  UPON  THE  THORAX. 

Incisions  for  Abscess  of  the  Breast. — These  should  radiate  from 
the  region  of  the  nipple  toward  the  periphery  of  the  breast  in  order 
to  avoid,  as  far  as  possible,  cutting  across  the  milk-ducts,  which  all 


208  THORAX. 

converge  toward  the  nipple.  The  incisions  should  be  liberal,  and 
should  be  so  placed  as  to  allow  the  discharge  to  drain  through  the 
lower,  dependent  part  of  the  breast,  and,  if  necessary  in  order  to 
accomplish  this,  one  or  more  counter-openings  may  be  made.  Liberal 
incisions  should  be  made  through  the  skin  and  fat,  and  the  abscess 
cavity  penetrated  with  closed  artery  forceps,  which  are  spread  apart 
as  they  are  withdrawn. 

Extirpation  of  Tumors  Out  of  the  Substance  of  the  Mammary 
Gland  (Fibroids,  for  Example). — An  incision  is  made  corresponding 
in  length  to  the  size  of  the  tumor  and  radiating  from  the  areola 
toward  the  periphery  of  the  breast. 

These  tumors  are  usually  encapsulated  and  well  defined,  and 
can  be  dissected  out  with  blunt-pointed  scissors  or  may  at  times  be 
enucleated  by  blunt  dissection  with  the  finger. 

Amputation  of  the  Breast. — The  patient  lies  upon  the  back  with 
the  arm  abducted.  The  incision  depends  upon  the  size  of  the  tumor 
and  the  condition  of  the  skin.  If  the  skin  is  involved  in  the  patho- 
logical process,  the  diseased  portion  should  be  sterilized  and  packed 
or  covered  with  gauze,  and  the  incision  placed  at  least  two  inches 
outside  of  the  affected  area  of  the  skin. 

The  incision  should  be  so  arranged  that  the  edges  of  the  wound 
may  be  brought  together  with  sutures,  after  the  breast  has  been 
removed,  for  the  purpose  of  obtaining  primary  union;  yet  one  should 
not  hesitate  to  sacrifice  all  suspicious  integument,  since  any  defect 
that  remains  may  be  covered  by  skin  grafting. 

The  usual  incision  is  one  which  includes  an  elliptical  area  of  the 
Bkinand  the  nipple,  set  obliquely  so  as  to  run  parallel  with  the  fibers 
of  the  pectoralis  major,  the  upper  end  of  the  ellipse  being  continued 
along  the  border  of  the  pectoralis  major  into  the  upper  arm  in  order 
to  empty  the  axilla.  The  edge  of  the  skin,  on  the  inner  side  of  the 
ellipse,  is  seized  with  the  fingers  or  a  thumb  forceps,  and,  including 
little  or  none  of  the  subcutaneous  fat,  is  separated  from  the  under- 
lying tumor  and  breast  beyond  its  farthest  limits  and  down  to  and 
exposing  the  surface  of  the  pectoralis  major  muscle. 

If  the  breast  (tumor)  is  not  adherent  to  the  pectoralis  major  it 
may  be  readily  detached  from  the  surface  of  this  muscle  with  the 
fingers,  and  then,  after  separating  the  skin  which  covers  the  outer 
part  of  the  breast,  it  may  be  turned  out  of  the  wound  ;  as  the  fascia, 
however,  which  covers  the  pectoralis  major  is  often  involved  in  the 
disease  even  when  apparently  healthy  (Volkmann),  it  is  better,  in 


OPERATIONS  UPON  THE  THORAX.  209 

all  cases,  to  remove  this  fascia,  together  with  the  superficial  portion 
of  the  muscle,  along  with  the  breast,  all  in  one  mass. 

At  times,  portions  of  the  mammary  gland,  partially  disconnected 
from  the  main  mass  of  the  gland  and  lying  in  the  adjacent  fat,  are 
difficult  to  recognize,  or  the  gland  itself  may  be  flattened  out  and 
difficult  to  identify,  or  a  portion  of  the  gland,  almost  completely 
detached  from  the  main  gland,  may  be  found  externally  under  the 
outer  border  of  the  pectoralis  major.  Care  must  be  exercised  to 
include  all  these  parts,  and  this  can  only  be  accomplished  by  ex- 
cising the  entire  gland  and  the  fat  in  which  it  is  imbedded,  together 
with  the  fascia  which  covers  the  pectoralis  major  and  the  superficial 
portion  of  this  muscle  and  the  contents  of  the  axilla,  all  in  one  mass. 

If  the  muscle  is  deeply  involved,  the  whole  muscle  down  to  the 
ribs  should  be  sacrificed,  and  it  may  even  be  necessary,  at  times,  to 
remove  the  surface  of  the  ribs;  but  these  are  rather  hopeless  cases 
at  best. 

After  the  breast  (tumor)  has  been  entirely  freed  from  the  skin 
and  pectoralis  muscle,  but  not  yet  detached,  cut  away,  at  its  axillary 
end,  the  axilla  is  opened  and  its  entire  contents — glands,  connective 
tissue,  fat,  etc. — excised  in  one  mass,  which  still  remains  continuous 
with  the  breast  (tumor). 

In  this  way  the  whole  axillary  space  is  completely  cleaned  out, 
working  close  along  the  course  of  the  axillary  vessels  and  adjoining 
nerves  and  ligating  all  vascular  branches  as  they  are  encountered. 
The  glands  that  are  involved  often  extend  high  up  into  the  axilla 
under  the  clavicle,  and  there  may  be  some  difficulty  in  removing 
these. 

The  axillary  vein  should  be  exposed  early  during  this  part  of 
the  operation.  It  rests  upon  the  tendon  of  the  latissimus  dorsi, 
which  is  the  guide  to  the  vessel,  below  and  to  the  inner  side  of  the 
axillary  artery.  The  axillary  vessels  are  accompanied  by  large  nerve 
trunks  and,  these,  together  with  the  vessels,  are  located,  all  in  a 
bunch,  close  to  the  humerus,  resting  upon  the  tendon  of  the  latis- 
simus dorsi,  beneath  the  edge  of  the  coraco-brachialis  and  the  short 
head  of  the  biceps.  If  the  vessels  are  thus  sought  for  and  exposed 
early  in  the  operation  they  are  less  liable  to  be  accidentally  injured. 
It  is  also  necessary  to  clean  out  the  space  between  the  pectoralis 
major  and  the  pectoralis  minor  muscles. 

If  the  mass  already  involves  the  axillary  vessels  and  nerves,  and 
this  is  usually  indicated  by  shooting  pains  in  the  arm  and  oedema 


210  THORAX. 

of  the  arm,  the  case  is,  at  best,  rather  hopeless,  and  it  is  questionable 
whether  the  operation  had  not  better  be  left  undone. 

In  clearing  out  the  axilla  some  large  arteries  and  veins  may  be 
severed,  but  these  may  be  clamped  and  ligated;  they  may  be  often 
seen  before  they  are  cut,  and  can  then  be  tied  before  they  are  divided, 
or  they  may  be  avoided. 

The  long  thoracic  nerve,  which  supplies  the  serratus  magnus, 
lies  upon  the  side  of  the  chest,  in  the  posterior  part  of  the  axillary 
space;  it  is  usually  seen  and  may  be  avoided,  although  it  is  of  but 
little  consequence  if  it  is  accidentally  divided.  One  should  also,  if 
possible,  avoid  the  long  subscapular  nerve  which  runs  in  company 
with  the  subscapular  vessels  upon  the  posterior  wall  of  the  axilla. 

If  the  clearing  out  of  the  axilla  is  commenced  below,  close  to 
the  under  border  of  the  pectoralis  major,  the  long  thoracic  artery 
and  vein  and  long  thoracic  nerve  are  encountered  early,  and  they 
may  be  avoided  or  used  as  guides  in  seeking  the  axillary  vein. 

During  the  operation  the  parts  must  be  well  retracted,  and,  in 
order  to  minimize  the  loss  of  blood  as  much  as  possible,  each  vessel 
should  be  clamped  as  it  is  cut,  and  that  part  of  the  wound  which  is 
not  under  immediate  consideration  compressed  with  hot  pads  to 
prevent  oozing.  The  bleeding  should  be  entirely  controlled  before 
the  wound  is  finally  closed. 

With  interrupted  sutures  the  edges  of  the  wound  are  coapted 
as  far  as  possible,  and  the  area  which  is  then  still  left  uncovered 
may  be  provided  with  skin  grafts.  It  is  wise  to  place  a  tube  in  the 
axilla  for  the  purpose  of  drainage. 

Amputation  of  the  Breast  (Halsted-Meyer).  —  The  breast,  to- 
gether with  the  pectoralis  major  and  minor  muscles  and  the  glands 
and  connective  tissue  of  the  axilla,  must  all  be  removed  in  one  single 
mass  and  without  cutting  into  the  diseased  tissue. 

An  incision  is  made  through  the  healthy  skin  and  fat,  elliptical 
and  circumscribing  the  tumor;  from  the  upper  end  of  the  ellipse 
the  incision  should  be  continued  along  the  edge  of  the  pectoralis 
major  to  a  point  upon  the  upper  part  of  the  arm  a  little  beyond 
(below)  the  attachment  of  the  tendon  of  this  muscle  to  the  humerus. 
Although  it  is  desirable  to  bring  the  edges  of  the  wound  together 
with  sutures  at  the  end  of  the  operation,  yet  one  should  not,  on  this 
account,  take  any  chance  in  leaving  suspicious  looking  integument, 
because  if  we  are  unable  to  close  the  wound  with  sutures  we  can 
cover  any  remaining  raw  space  with  skin  grafts. 


OPERATIONS  UPON  THE  THORAX. 


211 


To  this  first  incision  a  second  is  added  which  runs  obliquely 
from  the  junction  of  the  middle  and  outer  thirds  of  the  clavicle 
down  into  the  upper  border  of  the  elliptical  incision.  The  skin  flaps 
which  are  thus  marked  out,  and  including  little  or  no  fat,  are  then 
dissected  away  from  the  breast  (tumor)  and  well  beyond  its  periph- 
ery. In  this  way  we  expose  the  tendon  of  the  pectoralis  major  ex- 
ternally, the  border  of  the  latissimus  dorsi  below  and  externally, 
and  above  the  space  or  groove  between  the  edge  of  the  deltoid  and 
the  upper  border  of  the  pectoralis  major;  in  this  space  the  cephalic 


Fig.   88.— Amputation  of  the  Breast.     Halsted-Meyer  incision  for  amputation 
of  the  breast  and  to  clean  out  the  axilla. 


vein  and  the  descending  branch  of  the  acromio-thoracic  artery  are 
found. 

The  tendon  of  the  pectoralis  major  is  next  divided  close  to  its 
attachment  to  the  humerus,  and  then,  following  along  the  upper 
border  of  this  muscle,  between  it  and  the  edge  of  the  deltoid  as  far 
as  the  clavicle,  this  muscle  (pectoralis  major)  is  cut  away  from  its 
attachment  to  this  bone  (clavicle)  and  reflected  downward,  thus  ex- 
posing the  next  underlying  layer,  or  "Stage,"  which  consists  of  the 
pectoralis  minor  covered  by  its  fascia  and  some  loose  connective 
tissue.     The  fascia  that  covers  the  pectoralis  minor  is  continued 


212  THORAX. 

upward  from  the  inner  border  of  the  muscle  as  the  costo-coracoid 
membrane,  and  is  attached  to  the  first  rib  and  under  surface  of  the 
clavicle,  thus  covering  in  the  structures  of  the  infraclavicular  region. 
This  fascia,  costo-coracoid  membrane,  which  is  perforated  by  the 
cephalic  vein  and  other  structures,  is  now  cut  away  from  its  attach- 
ment to  the  clavicle,  and  we  thus  uncover  the  structures  of  this 
region,  namely:  the  first  part  of  the  axillary  artery;  the  axillary 
vein,  which  lies  along  the  inner,  lower  side  of  the  artery;  and  close 
to  the  vein  a  chain  of  lymphatic  vessels  and  nodes,  connective  tis- 
sue, and  fat.  The  nerve  trunks,  which  are  derived  from  the  brachial 
plexus,  run  parallel  with  the  vessels,  but  above  them.  All  these 
structures  pass  upward  and  inward,  under  the  clavicle  and  beyond 
the  first  rib,  into  the  root  of  the  neck. 

Commencing  as  high  up  as  possible,  the  space  beneath  the 
clavicle  being  made  more  accessible  by  elevating  the  shoulder,  all 
the  fat  and  connective  tissue  are  cleaned  away  from  the  vessels, 
ligating  all  branches  as  they  are  met  with  and  working  outward  and 
downward  along  the  course  of  the  vessels.  After  the  space  beneath 
and  above  the  clavicle  has  been  thoroughly  cleared  of  all  fat  and 
connective  tissue,  the  pectoralis  minor  is  cut  close  to  its  origin  from 
the  coracoid  process  and  reflected  downward,  together  with  the  con- 
nective tissue  and  fat  that  lie  upon  it  and  also  the  fat  and  connective 
tissue  that  are  found  underneath  it  adjacent  to  the  vessels  and  nerves 
in  this  part  of  the  axilla.  This  dissection  is  continued  down  along 
the  course  of  the  vessels  and  nerves  as  far  as  the  attachment  of  the 
tendon  of  the  pectoralis  major  to  the  humerus,  and  should  be  thor- 
ough. The  tissue  which  is  thus  removed  should  not  be  taken  away 
piecemeal,  but  dissected  free  from  the  vessels,  etc.,  in  one  continuous 
mass,  and  allowed  to  remain  connected  with  the  general  tumor  mass. 

Now,  from  the  posterior  wall  of  the  axilla  and  from  the  side  of 
the  chest,  all  the  fat  and  connective  tissue  and  lymphatic  tissue  are 
cleared,  working  from  behind  forward  and  laying  bare,  behind,  the 
anterior  surface  of  the  latissimus  dorsi,  subscapularis,  and  teres  ma- 
jor muscles  (posterior  wall  of  the  axillary  space)  and,  upon  the  side 
of  the  thorax,  the  ribs  and  serratus  magnus  muscle.  Upon  the 
posterior  wall  of  the  axilla  the  subscapular  nerve,  in  company  with 
the  subscapular  vessels,  is  encountered.  This  nerve  should  be  saved, 
if  possible,  and  likewise  the  vessels,  if  they  have  not  already  been 
cut. 

Upon  the  side  of  the  chest  we  meet  the  long  thoracic  vessels 


OPERATION'S  UPON  THE  THORAX.  213 

and  the  long  thoracic  nerve;  if  the  nerve  is  recognized  it  may  be 
possible  to  avoid  cutting  it. 

The  whole  mass — which  consists  of  the  breast  (tumor),  pectoral 
muscles  (major  and  minor),  axillary  contents,  etc. — is  now  grasped 
by  an  assistant  and  lifted  away  from  the  chest  wall  when  the  attach- 
ments of  the  pectoral  muscles  to  the  ribs  and  sternum  are  cut,  and 
then,  the  mass  being  gradually  turned  out  of  the  wound,  the  extirpa- 
tion is  completed  and  the  bare  wall  of  the  chest,  together  with  the 
axillary  vessels  and  the  nerves  which  accompany  them,  is  exposed  to 
view.  When  the  mass  is  lifted  away  from  the  chest  wall,  the  perfo- 
rating vessels — branches  of  the  intercostals  and  the  internal  mam- 
mary— may  be  seen  as  they  enter  the  posterior  surface  of  the  pec- 
toralis  major  and  care  should  be  taken  not  to  tear  these  or  cut  them 
too  close  to  the  surface  of  the  chest  wall,  as  it  might  then  be  difficult 
to  clamp  and  tie  them.  They  may  often  be  secured  with  clamps 
before  they  are  cut. 

The  edges  of  the  wound  are  brought  together  by  suture,  and 
if  too  much  integument  has  not  been  removed  the  wound  may  be 
thus  closed  entirely.  The  little  triangular  flap,  corresponding  to  the 
outer  edge  of  the  elliptical  incision,  is  turned  up  into  the  axilla  and 
fixed  there.  If  there  is  any  raw  space  remaining,  it  may  be  covered 
with  rubber  tissue  and  skin  grafted  later,  or  the  grafts  may  be  ap- 
plied at  once.  A  tube  may  be  placed  in  the  axilla  for  drainage,  and 
this  may  be  removed  on  the  sixth  or  seventh  day,  when  the  dressing 
is  changed. 

One  should  minimize  the  loss  of  blood  as  much  as  possible, 
clamping  vessels  before  or  immediately  after  they  are  cut. 

Ligation  of  the  Intercostal  Artery. — Each  intercostal  artery  is 
situated,  together  with  the  intercostal  vein  and  nerve,  beneath  the 
lower  border  of  the  corresponding  rib.  These  vessels  may  be  injured 
in  stab  wounds,  etc. 

At  times  it  becomes  necessary  to  resect  a  part  of  the  rib  sub- 
periosteally  in  order  to  get  at  the  bleeding  points.  It  is  necessary 
to  tie  both  ends  of  the  vessel. 

Ligation  of  the  Internal  Mammary  Artery.  —  To  secure  this 
vessel  one  must  resect  the  costal  cartilage  of  the  second  or  third 
rib  close  to  the  sternum  or  the  vessel  may  be  ligated  through  a 
transverse  incision  placed  midway  between  the  contiguous  cartilages 
and  close  to  the  sternum  in  the  third  intercostal  space.  The  vessel 
descends  upon  the  posterior  surface  of  the  anterior  chest  wall,  its 


214  THORAX. 

vein  alongside  of  it;  it  is  accompanied  also  by  a  chain  of  lymphatic 
nodes. 

Paracentesis  Pericardii. — Tapping  the  pericardium.  This  op- 
eration may  be  resorted  to  when  an  effusion  resists  other  measures  of 
treatment  or  when  it  is  causing  urgent  symptoms  of  cardiac  distress. 
The  puncture  is  made,  as  a  rule,  in  the  fifth  or  sixth  left  intercostal 
space  close  to  the  edge  of  the  sternum.  By  inserting  the  needle 
close  to  the  sternum  the  internal  mammary  vessels  are  avoided;  in 
the  sixth  interspace  there  is  still  less  likelihood  of  meeting  the  ante- 
rior free  edge  of  the  pleura  than  in  the  fifth;  therefore  the  sixth 
space  is  rather  preferable  except  that  occasionally  it  is  inconven- 
iently narrow. 

A  short  vertical  incision  is  made  through  the  skin  at  the  left 
edge  of  the  sternum  and  corresponding  to  the  fifth  or  sixth  inter- 
costal space. 

For  the  purpose  of  evacuation  a  trocar  and  cannula  may  be  used. 
If  the  sixth  space  is  selected  the  instrument  is  pushed  through  the 
intercostal  structures  in  a  direction  backward  and  inward.  If  the 
puncture  is  made  in  the  fifth  space  the  needle  is  entered  close  to  the 
edge  of  the  sternum  and  near  the  upper  border  of  the  sixth  costal 
cartilage  and  is  pushed  at  first  directly  backward  to  a  depth  of  about 
one-third  inch — the  thickness  of  the  sternum — and  then  inward 
behind  and  close  to  the  posterior  surface  of  the  sternum  for  a  dis- 
tance of  about  one-half  inch  in  order  to  make  certain  of  clearing  the 
edge  of  the  pleura  and  then,  finally,  backward  and  somewhat  down- 
ward and  inward  into  the  distended  pericardial  sac.  While  the  in- 
strument is  being  introduced  it  should  be  guarded  with  the  finger  to 
prevent  its  abruptly  entering  the  chest.  Fluid  may  be  evacuated 
with  or  without  aspiration,  depending  upon  the  facility  with  which 
it  escapes.  As  much  as  a  pint  has  been  withdrawn  at  a  single  op- 
eration. The  small  incision  in  the  skin  may  be  closed  with  a  single 
suture. 

Pericardiotomy. — Incision  of  the  pericardial  sac  in  order  to 
establish  drainage;  for  empyema.  The  fifth  costal  cartilage  is 
resected. 

An  incision  corresponding  to  the  fifth  left  costal  cartilage  is 
made.  It  commences  at  the  edge  of  the  sternum  and  exposes  the 
cartilage  for  its  whole  length.  The  soft  parts  are  detached  with  the 
elevator  and  the  cartilage  resected  with  the  bone-forceps.  The 
structures  corresponding  to  the  posterior  surface  of  the  cartilage  that 


OPERATIONS  UPON  THE  THORAX.  215 

has  been  resected,  are  divided  with  the  knife  and  the  internal  mam- 
mary vessels  exposed.  These  are  ligated  doubly  and  cut.  The  tri- 
angularis sterni, — a  flat  muscular  layer  that  is  interposed  between 
the  costal  cartilages  and  parietal  layer  of  the  pleura — is  exposed  to 
view;  it  should  be  incised  or  retracted  to  one  side.  The  pleura  is 
then  recognized  and  is  carefully  detached  from  the  edge  of  the  ster- 
num and  pericardial  sac  and  retracted  outward. 

The  pericardium  is  picked  up  with  two  toothed  forceps  and 
divided  between  these.  The  edges  of  the  opening  in  the  pericar- 
dium are  sutured  to  the  edges  of  the  deeper  layers  in  the  skin  in- 
cision. For  the  purpose  of  drainage  a  soft-rubber  drainage  tube  or  a 
plug  of  strip  gauze  may  be  introduced.  The  incision  in  the  skin  is 
sutured  in  part. 

Pericardiorrhaphy. — Suture  of  the  pericardium.  After  the  peri- 
cardial sac  has  been  exposed  the  edges  of  the  opening  or  wound  in 
it  are  brought  together  with  silk  or  catgut  sutures  in  such  fashion 
that  the  edges  are  everted  and  the  serous  surfaces  are  apposed.  The 
skin  incision  should  be  left  open  in  part  and  drained. 

Cardiorrhaphy. — Suture  of  the  heart;  for  wounds.  "Wounds  of 
the  heart  may  be  penetrating  or  non-penetrating  and  may  involve 
either  auricle  or  ventricle. 

For  purpose  of  suture  the  heart  must  be  freely  exposed  either 
by  resecting  the  fifth  left  costal  cartilage  (see  "Pericardiotomy")  or 
may  be  the  fourth,  fifth,  and  sixth  left  costal  cartilages;  or  else,  if 
still  more  room  is  required,  by  making  an  osteoplastic  resection  of 
the  sternum. 

If  the  heart  is  to  be  exposed  by  resecting  the  fourth,  fifth,  and 
sixth  costal  cartilages  a  vertical  incision  is  made  parallel  with  and 
about  one  finger's  breadth  away  from  the  left  border  of  the  sternum 
and  reaching  from  the  upper  border  of  the  third  to  the  lower  border 
of  the  sixth  or  to  the  seventh  costal  cartilage.  To  this  may  be  added 
a  short,  transverse  incision  at  the  upper  end,  corresponding  to  the 
fourth  costal  cartilage,  and  another  at  the  lower  end,  corresponding 
to  the  sixth  costal  cartilage.  The  cartilages  are  denuded  with  the 
periosteum  elevator  and  resected  with  the  bone-forceps.  The  inter- 
costal muscles,  etc.,  are  incised  and  the  internal  mammary  vessels  ex- 
posed, ligated  doubly,  and  divided.  The  triangularis  sterni,  the  thin 
muscular  sheet  that  is  spread  out  upon  the  posterior  aspect  of  the  costal 
cartilages,  etc.,  between  these  and  the  pleura,  is  exposed.  This  layer  is 
incised  or  drawn  to  one  side.    The  pleura  is  separated  from  the  poste- 


216  THORAX. 

rior  aspect  and  the  edge  of  the  sternum  and  from  the  pericardium  and 
retracted  outward. 

Where  more  room  is  required  the  pericardial  sac  may  he  exposed 
by  raising  a  trap-door  flap  consisting  of  the  soft  parts  and  the  lower 
portion  of  the  body  of  the  sternum.  A  vertical  incision  is  made  from 
the  third  to  the  sixth  costal  cartilage  close  to  the  left  edge  of  the 
sternum  so  as  to  avoid  the  internal  mammary  vessels  and  exposing 
the  third,  fourth,  and  fifth  costal  cartilages.  Corresponding  to  the 
upper  and  lower  ends  of  this  vertical  incision  a  transverse  cut  is 
made  across  the  front  of  the  sternum  down  to  the  bone.  In  the  line 
of  the  vertical  incision  the  costal  cartilages  are  exposed  and  divided 
with  the  bone-forceps.  After  the  cartilages  have  been  thus  divided 
the  edge  of  the  sternum  is  lifted  up  with  a  pronged  retractor  and 
the  soft  parts  separated  from  its  posterior  aspect  with  a  periosteum 
elevator  slightly  bent  upon  itself.  Corresponding  to  the  line  of  the 
upper  and  the  lower  transverse  incisions,  the  sternum  is  divided 
completely  across,  using  the  Gigli  wire  saw  or  the  bone-forceps  for 
this  purpose.  The  osteo-tegumentary  flap  which  is  thus  marked  off 
and  which  includes  the  segment  of  the  sternum  is  bent  over  toward 
the  right  side;  the  third,  fourth,  and  fifth  right  costal  cartilages 
being  broken  in  order  to  accomplish  this.  The  pericardial  sac  is 
thus  exposed. 

Whichever  method  has  been  employed,  after  the  pericardial  sac 
has  been  exposed  the  incision  or  wound  in  the  sac  is  enlarged  with 
the  scissors  sufficiently  to  permit  of  access  to  the  heart.  The  peri- 
cardial sac  may  be  distended  with  blood,  which  must  be  evacuated, 
or  the  pleura  may  be  wounded  and  a  condition  of  hsemothorax  may 
be  present. 

Wounds  of  the  heart  should  be  sutured  with  moderately  fine 
silk.  The  sutures  are  introduced  with  a  full-curved  slender  sur- 
geon's needle  or  with  a  round  curved  intestinal  needle  in  a  holder. 
The  sutures  are  inserted,  drawn  tight,  and  tied  during  diastole  only; 
for  instance,  a  single  suture  is  passed  during  one  diastole,  drawn 
tight  during  a  subsequent  one,  and  tied  during  a  third.  The  sutures 
should  take  a  good,  secure  bite,  but  should  not  penetrate  as  deep  as 
the  endocardium:  they  should  not  penetrate  the  entire  thickness  of 
the  heart  wall.  The  ends  of  the  first  suture  may  be  left  long  to  serve 
as  a  tractor  and  steady  the  heart  during  the  introduction  of  the  sub- 
sequent stitches. 

A  severed  coronary  artery  should  be  ligated. 


OPERATIONS  UPON  THE  THOPvAX.  217 

The  opening  in  the  pericardium  may  he  closed  with  sutures, 
hut  it  is  probably  wise  to  leave  it  partly  open  with  a  narrow  strip  of 
gauze  for  drainage,  etc. 

If  the  osteoplastic  resection  of  the  sternum  has  been  made  in 
order  to  expose  the  heart,  the  segment  of  the  sternum  may  be 
secured  in  place  with  several  silver  wire  sutures. 

The  incision  in  the  skin  is  closed  except  for  a  small  space  through 
which  the  gauze  drainage  strip  emerges. 

Thoracentesis. — Puncture  through  the  chest  wall  into  the  pleu- 
ral cavity. 

This  operation  may  be  performed  to  show  the  presence  and  to 
determine  the  nature  of  fluid  in  the  pleural  cavity  or  to  evacuate  such 
fluid.  If  for  diagnosis  only,  an  ordinary  hypodermic  syringe  may  be 
used.  If  necessary  to  evacuate  a  considerable  quantity  of  fluid,  a  rather 
good  sized  aspirating  needle  attached  to  a  Dieulafoy  syringe  may  be 
employed.  The  patient  should  be  semirecumbent  or  lying  down.  The 
puncture  should  be  made  at  the  point  where  the  physical  signs  locate 
the  fluid.  To  anaesthetize  the  skin  a  spray  of  ethyl  chloride  may  be 
used.  Before  the  needle  is  introduced,  the  skin  is  drawn  upward  or 
downward  so  that  the  track  of  the  needle  through  the  muscles  may  not 
be  upon  the  same  level  as  the  puncture  in  the  skin.  The  needle  is 
thrust  into  the  chest  between  the  two  ribs,  nearer  the  lower  than  the 
upper  one. 

If  the  operator  may  choose  the  point  at  which  the  needle  is  to  be 
introduced,  either  the  eighth  space,  just  below  the  angle  of  the  scapu- 
lar, or  the  sixth  space,  in  the  middle  of  the  axilla,  just  in  front  of  the 
border  of  the  latissimus  dorsi,  is  usually  selected. 

The  fluid  should  be  evacuated  slowly,  and,  if  the  quantity  is  great, 
care  should  be  taken  not  to  remove  too  much.  One  should  stop  if  per- 
sistent cough  occurs  or  if  the  pulse  changes.  At  times,  the  needle 
becomes  plugged  with  pieces  of  fibrin,  which  may  be  dislodged  by 
introducing  a  stylet  or  by  pumping  some  of  the  fluid  back  into  the 
pleural  cavity.  After  the  fluid  has  been  withdrawn  the  needle  is 
removed  and  the  small  wound  in  the  skin  covered  with  collodion,  etc. 

It  is  necessary  to  remember  that  the  lower  limits  of  the  pleural 
cavity  fall  short  of  the  free  border  of  the  ribs,  and,  further,  that  if  the 
needle  is  inserted  straight  inward  for  a  considerable  distance  it  may 
pass  through  the  pleura  and  diaphragm  into  the  abdominal  cavity. 

If  we  find  pus  in  the  pleural  cavity,  in  the  adult,  it  is  necessary 
to  establish  drainage,  resecting  part  of  a  rib.     In  the  child  it  often 


218  THORAX. 

suffices  to  simply  evacuate  the  pus  with  the  needle  without  providing 
drainage. 

Thoracotomy. — This  means  cutting  through  the  wall  of  the  chest, 
usually  with  the  resection  of  part  of  a  rib,  for  the  purpose  of  estab- 
lishing drainage. 

The  patient  lies  upon  his  well  side,  and  should  be  anaesthetized. 
The  seventh  rib,  that  portion  of  it  which  lies  anterior  to  the  latis- 
simus  dorsi,  is  usually  resected,  as  this  is  not  covered  by  muscle  and 
is  sufficiently  low  for  proper  drainage. 

Immediately  before  proceeding  with  the  operation  the  exploring 
needle  should  be  inserted  in  order  to  ascertain  positively  the  location 
of  the  pus,  and  there,  where  the  pus  is  located,  should  the  opening 
into  the  pleural  cavity  be  made.  As  already  mentioned,  if  we  have 
the  choice,  the  seventh  rib  is  the  one  selected  for  resection. 

The  incision,  usually  about  two  inches  long,  corresponds  to  the 
course  and  direction  of  the  rib  to  be  excised;  it  is  carried  down 
through  the  soft  parts,  including  the  periosteum,  upon  the  surface 
of  the  rib.  With  the  elevator  the  periosteum  and  all  the  soft  parts 
are  peeled  off  the  bone,  which  is  thus  laid  bare.  Care  must  be  ex- 
ercised, in  working  around  the  upper  and  lower  borders  of  the  rib 
for  the  purpose  of  denuding  its  internal  surface,  not  to  perforate  the 
pleura  nor  wound  the  vessels  that  are  lodged  in  the  groove  along  the 
lower  border  of  the  rib.  When  the  length  of  bone  that  is  to  be  excised 
has  been  denuded  of  its  periosteum  it  is  cut  through  at  either  end 
with  the  sharp  bone  forceps.  The  opening  into  the  chest  cavity  is 
made  by  incising  the  pleura  with  the  knife.  The  opening  which  is 
thus  made  may  be  enlarged  by  introducing  an  artery  forceps,  the 
blades  of  which  are  spread  apart  as  they  are  withdrawn  so  as  to  make 
a  hole  large  enough  to  permit  exploration  of  the  interior  of  the  chest 
with  the  finger  and  the  introduction  of  one  or  two  good-sized  tubes. 

If  it  is  discovered,  with  the  ringer  in  the  chest,  that  the  opening 
is  a  considerable  distance  above  the  bottom  of  the  pus  cavity,  it  may 
be  desirable,  in  order  to ,  facilitate  the  drainage,  to  make  a  second 
counter-opening  at  a  lower  level :  through  the  eighth  space,  for  in- 
stance, or  even  lower,  depending  upon  the  part  of  the  chest  which  is 
involved  (see  limits  of  lower  edge  of  pleura).  The  drainage  tube 
should  be  secured  to  the  edge  of  the  incision  in  the  skin  with  a  silk 
stitch  in  order  to  prevent  its  becoming  dislodged.  If  the  skin  wound 
is  unnecessarily  large,  it  may  be  partially  closed  with  one  or  two  silk 
sutures.    The  administration  of  20  or  30  minims  of  aromatic  spirits 


OPERATIONS  UPON  THE  THORAX.  219 

of  ammonia  hypodermically,  immediately  before  the  opening  is  made 
into  the  pleural  cavity,  will  often  ward  off  the  condition  of  collapse 
which  sometimes  occurs  at  this  time. 

Thoracectomy,  Resection  of  the  Chest  Wall  (Estlaender). — An 
oval  or  U-shaped  flap,  consisting  of  the  skin  and  subcutaneous  fat, 
with  its  base  behind,  at  the  axillary  line,  is  raised  from  the  side  of  the 
chest,  exposing  three  or  four  ribs;  or  a  vertical  incision,  six  inches 
long,  may  be  made  in  the  axillary  line  over  the  fifth,  sixth,  seventh, 
and  eighth  ribs,  with  two  additional  incisions  along  the  course  of 
the  ribs,  the  middle  of  each  of  these  accessory  incisions  correspond- 
ing to  the  upper  and  lower  ends  of  the  vertical  incision.  The  two 
flaps  which  are  thus  marked  out  are  reflected,  one  backward  and  the 
other  forward,  exposing  four  to  six  inches  of  three  or  four  ribs. 

Each  rib  is  denuded  of  its  periosteum  all  around,  as  described 
in  the  preceding  operation,  and  resected  with  the  bone  pliers.  A  long 
incision  is  then  made  in  the  pleura  and  the  thickened  pleura  excised. 
The  bleeding  is  controlled  by  clamps  and  ligatures.  The  cavity  of 
the  pleura  may  be  curetted  if  thought  necessary.  The  edges  of  the 
skin  flap  are  brought  together  with  several  silk  sutures  and  the  pleural 
cavity  packed. 

Pleurectomy  (Fowler). — Detachment  and  excision  of  the  thick- 
ened, diseased  pleura,  visceral  and  parietal,  entire  or  in  part,  in  old, 
intractable  cases  of  empyema. 

An  incision  is  made  along  the  course  of  the  ribs  corresponding 
to  the  site  of  the  fistula,  which  is  always  present  (since  this  operation 
is  usually  practiced  in  cases  which  have  already  been  operated  upon 
unsuccessfully),  and  the  location  of  the  disease;  to  either  end  of  this 
incision  there  may  be  added  accessory  incisions,  an  anterior  and  a 
posterior.  The  flaps  that  are  thus  marked  out,  including  all  the  soft 
parts,  are  raised  so  as  to  expose  two  or  three  ribs  for  four  or  five 
inches  of  their  length.  Instead  of  the  incision  as  described  above  an 
elliptical  or  the  double  flap  incision,  as  described  in  the  Estlaender 
operation,  may  be  employed. 

The  periosteum  is  stripped  off  two  or  three  ribs  with  the  ele- 
vator, and  then  from  three  to  five  inches  of  the  two  or  three  ribs 
that  have  been  thus  denuded  are  resected  with  the  bone  forceps. 
All  bleeding  points  should  be  clamped  and  ligated.  Cutting  from 
the  fistula,  the  parietal  (costal)  pleura,  which  is  now  exposed,  is 
opened  up  with  a  free  incision,  and  entrance  thus  gained  into  the 
suppurating  pleural  cavity.    The  pleura  which  invests  the  lung  (vis- 


220  THORAX. 

ceral)  is  incised,  and  by  blunt  dissection  with  the  finger  or  blunt- 
pointed  scissors  this  is  peeled  off  the  lung;  here  and  there  it  will  be 
necessary  to  cut  a  band  with  the  scissors.  In  many  cases  the  pleura 
may  be  separated  from  the  lung  with  comparative  ease,  and  this  should 
be  done  with  care,  so  as  not  to  tear  into  the  lung  tissue  proper. 

As  the  decortication  of  the  lung  progresses  there  may  be  con- 
siderable oozing  from  the  denuded  ■  lung  surface,  but  this  may  be 
controlled  by  compression  with  gauze  pads,  which  are  applied  to  the 
bleeding  surface  following  up  the  fingers  of  the  operator  or  the  blunt 
scissors,  according  as  the  pleura  is  detached. 

After  the  pleura  has  been  peeled  off  the  lung  the  parietal  pleura 
is  stripped  off  the  chest  wall  and  then  off  the  diaphragm.  In  sepa- 
rating the  pleura  from  the  contiguous  portion  of  the  pericardial  sac 
care  must  be  exercised  to  avoid  any  undue  pulling  or  tearing.  As 
a  rule,  the  pleura  is  fairly  easily  separated  and  removed. 

At  times  it  will  be  found  more  convenient  to  commence  the  de- 
tachment of  the  pleura  by  stripping  it  away  from  the  chest  wall;  it 
is  then  peeled  off  the  diaphragm  and  finally  from  the  surface  of  the 
lung. 

Occasionally  the  conditions  that  exist  preclude  the  possibility 
of  excising  all  of  the  diseased  pleura,  and  under  these  circumstances 
the  operator  must  content  himself  with  the  excision  of  the  visceral 
or  parietal  (costal  and  diaphragmatic)  pleura  in  part,  or  else  simply 
incise  the  visceral  pleura  and  strip  it  away  from  the  surface  of  the 
lung  without  removing  it. 

After  the  pleura  has  been  removed,  either  entire  or  in  part,  the 
cavity  in  the  chest  is  loosely  tamponed  with  gauze  and  the  edges  of 
the  skin  approximated  with  silk-worm  gut  sutures,  except  for  a  part 
of  its  extent,  where  the  tampon  emerges. 

As  a  rule,  as  a  detachment  of  the  pleura  from  the  lung  progresses, 
the  lung  will  be  seen  gradually  to  expand  more  and  more. 

This  operation  has  the  advantage  of  removing  the  pathological 
suppurating  membrane,  and  besides  eliminates  an  obstacle  to  the 
expansion  of  the  lung.  The  operation  is  not  advisable  in  cases  of 
diagnosible  pulmonary  tuberculosis.  The  discovery,  during  the  course 
of  the  operation,  of  tuberculous  deposits  in  the  lung  would  warrant 
the  surgeon  in  discontinuing  the  operation. 


PART  V. 

THE   ABDOMEN   AND   BACK. 


THE  ABDOMEN. 

The  abdomen  corresponds  to  the  lower  part  of  the  trunk,  and 
consists  of  a  cavity  with  elastic  muscular  walls. 

Within  the  cavity  are  contained  the  chief  part  of  the  alimentary 
canal  and  the  organs  of  digestion  and  the  kidneys,  etc.  These  organs 
are  all  more  or  less  movable,  and  are  provided  with  a  more  or  less 
complete  investment  of  peritoneum. 

Externally  the  abdomen  is  limited  above  by  the  free  border  of 
the  costal  cartilages  and  below  by  the  crest  of  the  iliac  bone  of 
either  side  and  Poupart's  ligaments.  The  walls  consist  almost  en- 
tirely of  soft  parts,  and  may  be  conveniently  considered  as  the  poste- 
rior and  the  antero-lateral.  The  capacity  of  the  abdominal  cavity  is 
greater  than  is  indicated  by  its  external  limitations. 

The  roof  of  the  abdominal  cavity  is  formed  by  the  diaphragm; 
below,  the  abdominal  cavity  includes,  on  either  side,  the  iliac  fossa 
and  communicates  through  a  wide,  heart-shaped  opening  with  the 
cavity  of  the  true  pelvis.  The  margin  of  the  inlet  into  the  pelvic 
cavity  is  called  the  pelvic  brim. 

The  interior  of  the  cavity  of  the  abdomen  is  lined  by  the  parietal 
layer  of  the  peritoneum,  and  is  entirely  shut  off  from  communica- 
tion with  the  exterior  of  the  body  except  in  the  female,  where  a 
communication  exists  through  the  vagina,  uterus,  and  Fallopian 
tubes,  and  this  is  frequently  the  channel  through  which  infection 
is  carried  to  the  peritoneum  from  without. 

The  Diaphragm,  which  forms  the  roof  of  the  abdominal  cavity, 
is  a  musculo-aponeurotic  structure  that  separates  the  cavity  of  the 
chest  from  that  of  the  abdomen.  It  is  dome-shaped,  bulging  into 
the  cavity  of  the  thorax  and  presenting  its  lower  concave  surface  to 
the  abdominal  cavity.  It  arises  by  muscular  fibers,  which  vary  in 
length,  from  the  inner  surface  of  the  ensiform  process  of  the  ster- 
num and  from  the  inner  surface  of  the  cartilages  of  the  lower  ribs. 
Behind,  it  arises  from  the  ligamentum  arcuatum  externum  and  liga- 
mentum  arcuatum  internum  and  by  its  two  crura  from  the  anterior 

(221) 


222  ABDOMEN  AND  BACK. 

surface  of  the  bodies  of  the  three  upper  lumbar  vertebrae.  From 
these  points  of  origin  the  muscular  fibers  converge  and  are  continued 
into  a  three-leafed  aponeurotic  structure:  the  central  tendon  of  the 
diaphragm.  Behind  the  diaphragm  there  is  an  opening,  the  aortic, 
through  which  the  aorta  passes  from  the  thoracic  into  the  abdom- 
inal cavity;  the  posterior  boundary  of  this  opening  corresponds 
to  the  body  of  the  twelfth  dorsal  vertebra.  In  the  back  part  of  the 
diaphragm,  a  little  to  the  left  of  the  middle  line,  there  is  an  open- 
ing which  is  surrounded  by  muscular  fibers  and  through  which 
the  oesophagus  passes  to  the  cardiac  end  of  the  stomach.  To  the 
right  of  the  middle  line,  toward  the  front,  at  the  junction  of  the 
right  and  middle  segments  of  the  central  tendon,  there  is  an  opening 
for  the  passage  of  the  inferior  vena  cava;  the  edges  of  this  opening 
are  formed  of  aponeurotic  fibers.  The  heart,  wrapped  in  its  peri- 
cardial sac,  rests  upon  the  upper  surface  of  the  central  tendon  of  the 
diaphragm. 

In  front,  close  to  the  sternum,  on  either  side  of  the  bundle  of 
fibers  which  arises  from  the  ensiform  process,  there  is  a  space  where 
the  muscular  fibers  of  the  diaphragm  are  absent;  so  that,  in  this 
situation,  an  opening  exists  through  which  the  contents  of  one  cavity 
may  be  forced  into  the  other,  giving  rise  to  a  so-called  diaphragmatic 
hernia. 

On  the  right  side,  owing  to  the  presence  of  the  liver,  the  dia- 
phragm reaches  higher  into  the  chest  than  on  the  left.  The  thoracic 
surface  of  the  diaphragm  is  covered  by  a  thin  fascia,  the  fascia  endo- 
thoracica;  the  abdominal  surface  is  likewise  covered  by  a  fascia 
which  is  very  thin,  the  fascia  transversalis. 

The  Posterior  Wall  of  the  Abdomen,  the  lumbar  region  of  the 
back,  corresponds  to  the  five  lumbar  vertebrae  and  to  the  several 
muscles  which  fill  in  the  space  between  the  last  rib  and  the  crest 
of  the  ilium  on  either  side  of  the  spinal  column.  Externally  we  find 
the  skin  and  beneath  this  the  subcutaneous  fatty  layer.  Between 
the  muscles  of  the  lumbar  region  there  are  interposed  strong  layers  of 
fascia  which  serve  to  strengthen  this  region  very  much.  The  in- 
ternal or  abdominal  aspect  of  the  posterior  wall  of  the  abdomen  is 
lined  by  that  part  of  the  transversalis  fascia  which  covers  the  psoas 
and  quadratus  lumborum  muscles. 

The  kidney,  inclosed  within  its  fatty  capsule,  is  located  in  the 
lumbar  region  between  the  transversalis  fascia — i.e.,  the  anterior 
layer  of  the  lumbar  fascia — and  the  parietal  peritoneum,  its  ante- 


ABDOMEN.  223 

rior  surface  only  being  covered  by  the  peritoneum ;  so  that  the  organ 
is  thus  excluded  from  the  peritoneal  cavity. 

The  Antero-Lateral  Wall  of  the  Abdomen  is  made  up  of  several 
layers  of  soft  parts.  It  consists  of  the  skin  with  its  underlying  fatty 
layer;  several  broad,  flat  muscles,  the  oblique,  the  transversalis,  and 
the  recti;  and  the  aponeuroses  which  correspond  to  these  muscles. 
The  fascia  transversalis  is  found  beneath  the  muscles,  and  beneath 
the  fascia  transversalis  the  subperitoneal  fat  is  encountered,  and, 
finally,  deepest,  most  internal  of  all,  is  the  parietal  peritoneum. 

In  the  female  the  abdomen  is  more  rounded  and  contains  a  con- 
siderable pad  of  fat;  in  the  male,  especially  in  athletes,  the  fatty 
layer  is  less  marked  or  almost  entirely  absent;  so  that  the  markings 
of  the  muscles  show  through  the  skin  and  give  the  characteristic 
appearance  to  the  abdomen. 

In  the  middle  line,  about  midway  between  the  ensiform  process 
and  the  symphysis  pubis,  there  is  a  well-marked  depression,  the  navel; 
this  is  an  important  landmark,  although  its  position  may  vary  some- 
what in  different  individuals,  and  marks  the  place  where  the  foetal 
umbilical  vessels  and  foetal  channels  enter  and  pass  out  of  the  abdo- 
men. Above,  in  the  middle  line,  is  the  ensiform  process  of  the  ster- 
num, and  passing  downward  from  this  there  is  a  furrow  which  corre- 
sponds to  the  space  between  the  rectus  muscles,  but  which  does  not 
reach  downward  as  far  as  the  symphysis.  On  either  side  of  the 
middle  line,  corresponding  to  the  outer  border  of  the  rectus,  is  the 
location  of  the  linea  semilunaris.  Below,  on  either  side,  the  anterior 
superior  iliac  spines — important  surgical  landmarks — may  be  seen, 
and  upon  the  pubic  bones,  on  either  side  of  and  close  to  the  sym- 
physis, the  spinous  processes  of  the  pubes  may  be  felt. 

Corresponding  to  Poupart's  ligament,,  which  reaches  from  the 
anterior  superior  spine  to  the  spine  of  the  pubes,  there  is  a  linear 
crease  in  the  skin  which  separates  the  abdomen  from  the  front  of 
the  thigh. 

The  whole  abdomen  is  covered  by  the  skin,  underneath  which 
is  the  subcutaneous  fat;  the  abdomen  is  a  favorite  site  for  the  accu- 
mulation of  fat  in  the  obese,  and  this  layer  varies  much  in  thickness 
in  different  individuals;  it  is  continuous  with  the  corresponding 
fatty  layer  upon  the  breast  and  below  with  the  fat  of  the  thighs. 
At  the  navel  the  fat  is  absent,  the  skin  being  depressed  and  fixed 
to  the  aponeurosis  beneath,  so  that  the  depth  of  the  navel  corre- 
sponds to  the  thickness  of  the  abdominal  pad  of  fat.    The  subcuta- 


224  ABDOMEN  AND  BACK. 

neous  fatty  layer  may  be  readily  separated  from  the  underlying  mus- 
cle and  aponeurosis,  leaving  these  structures  covered  by  a  thin,  loose, 
cellular  fascia,  the  so-called  deep  layer  of  the  superficial  fascia,  but 
which  is  really  a  part  of  the  subcutaneous  connective-tissue  layer. 
This  fascia  is  more  intimately  attached  to  the  linea  alba  and  Pou- 
parf  s  ligament  and  to  the  pillars  of  the  external  inguinal  ring  than 
elsewhere.  From  the  pillars  of  the  ring  it  is  prolonged  downward 
around  the  spermatic  cord  and  into  the  scrotum,  where  it  is  con- 
tinuous with  the  dartos. 

The  Superficial  Vessels  of  the  Abdominal  Wall. — In  the  subcu- 
taneous fatty  layer  the  superficial  arteries  and  veins  ramify. 

Above,  branches  of  the  superior  epigastric,  which  perforate  the 
rectus  and  the  anterior  layer  of  its  sheath,  are  distributed  to  the 
integument  and  subcutaneous  tissue.  Below,  the  superficial  epi- 
gastric artery,  which  is  derived  from  the  femoral,  curves  obliquely 
upward  across  Poupart's  ligament  toward  the  umbilicus  and  supplies 
the  skin  and  fat  in  this  region.  Upon  the  sides  of  the  abdomen 
branches  that  are  given  off  from  the  lumbar  arteries  pierce  the  mus- 
cles and  ramify  in  the  subcutaneous  tissue.  These  vessels  are  all 
accompanied  by  their  corresponding  veins.  Underneath  the  skin 
of  the  abdomen  are  seen  many  large  veins  which  communicate  with 
those  within  the  abdomen,  and  therefore  when  the  blood-current  is 
obstructed  in  the  portal  vein  or  the  vena  cava  these  superficial  ab- 
dominal veins  become  swollen  and  prominent  and  are  readily  recog- 
nized beneath  the  skin. 

After  the  skin  and  subcutaneous  fatty  layer,  including  the  thin 
deep  layer  of  the  superficial  fascia,  have  been  removed  from  the 
front  and  sides  of  the  abdomen,  the  broad,  strong  aponeurosis  of  the 
external  oblique  upon  the  front  of  the  abdomen  and  the  fleshy  por- 
tion of  this  same  muscle  upon  the  side  of  the  abdomen  are  exposed. 

The  Muscles  of  the  Antero-Lateral  Wall.  The  Extekntal 
Oblique  is  a  broad,  flat  muscle,  the  most  superficial  of  the  abdom- 
inal muscles,  and  occupies  the  side  of  the  abdomen.  The  muscle 
arises  by  fleshy  slips  from  the  external  surface  of  the  eight  lower 
ribs,  interdigitating  with  the  processes  of  origin  of  the  pectoralis 
major  and  the  latissimus  dorsi.  The  fibers  of  this  muscle  have  a 
general  oblique  direction,  downward,  forward,  and  inward,  terminat- 
ing in  the  broad,  strong  aponeurosis  which  occupies  the  front  of  the 
abdomen.  Those  fibers  which  arise  from  the  lowest  ribs  pass  almost 
directly  downward  and  are  attached  to  the  anterior  half  of  the  outer 


ABDOMEN.  225 

lip  of  the  crest  of  the  ilium.  The  posterior  free  border  of  the  ex- 
ternal oblique  muscle  forms  the  anterior  border  of  the  triangle  of 
Pettit.  The  posterior  border  of  this  triangle  is  formed  by  the  outer 
free  edge  of  the  latissimus  dorsi,  its  base  by  the  crest  of  the  iliac 
bone,  its  floor  by  the  internal  oblique  muscle. 

The  aponeurosis  of  the  external  oblique  is  a  broad,  strong,  pearly 
white,  glistening,  fibrous  structure  which  occupies  the  front  of  the 
abdomen  and  is  exposed  after  the  integument  and  underlying  fatty 
layer  (superficial  fascia)  have  been  removed.  The  fibers  of  the  apo- 
neurosis are,  for  the  most  part,  directed  downward  and  inward,  cov- 
ering in  the  recti  and  joining  in  the  middle  line,  between  these 
muscles,  to  form  the  linea  alba. 

The  linea  alba  is  a  strong,  fibrous  band  which  reaches  from  the 
ensiform  cartilage  above  to  the  symphysis  pubis  below;  it  marks  the 
union  of  the  aponeuroses  of  either  side  and  separates  the  recti  from 
each  other.  The  linea  alba  is  interrupted  by  the  navel.  Above  the 
navel  the  linea  alba  is  broad:  in  the  epigastric  region  it  is  1  to  2 
cm.  wide,  and  below,  toward  the  navel,  becomes  still  broader.  Below 
the  navel,  however,  it  is  not  so  broad,  owing  to  the  closer  approxi- 
mation of  the  edges  of  the  recti.  Above,  where  it  is  broad,  it  is  thin 
from  before  backward,  and  below,  where  it  is  narrow,  it  is  thick 
from  before  backward.  Below,  at  its  attachment  to  the  symphysis 
pubis,  it  spreads  out  and  is  known  as  the  adminiculum  lineae  albas. 

Those  fibers  of  the  aponeurosis  of  the  external  oblique,  that 
pass  from  the  anterior  superior  spine  of  the  ilium  downward  and 
inward  to  the  spine  of  the  pubes,  form  Poupart's  ligament;  where 
this  ligament  is  attached  to  the  pubic  spine,  the  aponeurosis  of  the 
external  oblique  splits  and  leaves  a  triangular  opening  which  is  called 
the  external  inguinal  ring,  and  through  this  the  spermatic  cord  in 
the  male,  and  the  round  ligament  in  the  female,  emerge.  Below  Pou- 
part's, the  aponeurosis  is  continuous  with  the  fascia  lata  of  the  front 
of  the  thigh. 

Along  the  outer  edge  of  the  rectus,  at  the  linea  semilunaris,  the 
aponeurosis  of  the  external  oblique  is  blended  with  the  aponeuroses 
of  the  underlying  muscles;  from  the  linea  semilunaris  the  aponeu- 
rosis is  continued  inward,  forming  the  anterior  layer  of  the  sheath 
of  the  rectus,  and  in  the  middle  line  joins  with  that  of  the  opposite 
side  to  form  the  linea  alba. 

The  Internal  Oblique  Muscle  lies  beneath  the  external 
oblique  upon  the  side  of  the  abdomen,  a  thin,  loose,  cellular  con- 


22 G  ABDOMEN  AND  BACK. 

nective  tissue  being  interposed  between  them.  The  fibers  of  this 
muscle  have  a  direction  the  opposite  to  those  of  the  external  oblique. 

This  muscle  arises  below  from  the  anterior  two-thirds  of  the 
middle  lip  of  the  crest  of  the  ilium  and  from  the  outer  half  of 
Poupart's  ligament.  From  this  origin  the  fibers  pass  in  a  general 
direction  upward  and  forward,  some  being  attached  to  the  lower 
border  of  the  cartilages  of  the  four  lower  ribs,  the  others  terminat- 
ing in  the  anterior  aponeurosis,  at  the  outer  border  of  the  rectus, 
the  linea  semilunaris.  The  lowermost  fibers,  which  arise  from  Pou- 
part's ligament,  pass  inward  and  then,  curving  downward,  join  with 
a  similar  process  from  the  transversalis  to  form  the  conjoined  tendon, 
which  is  attached  to  the  crest  of  the  os  pubis. 

The  Transversalis  is  the  deepest  of  the  three  broad  abdom- 
inal muscles.  It  occupies  the  side  of  the  abdomen  lying  next  beneath 
the  internal  oblique,  a  thin,  loose,  cellular  connective  tissue  inter- 
vening between  them.  Its  fibers  have  a  transverse  direction.  This 
muscle  arises  behind,  through  the  lumbar  fascia,  from  the  transverse 
processes  and  spines  of  the  lumbar  vertebrae;  above,  from  the  inner 
surface  of  the  six  lower  ribs;  below,  from  the  crest  of  the  ilium  and 
the  outer  one-third  of  Poupart's  ligament.  The  fibers  pass  forward 
and  inward,  and,  at  the  outer  border  of  the  rectus,  terminate  in  the 
anterior  aponeurosis.  Those  fibers  of  the  transversalis  which  arise 
from  Poupart's  ligament  pass  inward,  and  curving  downward  join 
with  a  similar  process  from  the  internal  oblique  to  form  the  con- 
joined tendon,  which  is  attached  to  the  crest  of  the  pubes  behind 
the  external  inguinal  ring.  Beneath  the  transversalis  muscle,  the 
transversalis  fascia,  which  lines  the  whole  inner  surface  of  the  ab- 
domen, is  found. 

The  Pectus  is  a  long,  flat  muscle  occupying  the  front  of  the 
abdomen,  one  on  either  side  of  the  middle  line,  the  linea  alba  being 
interposed  between  them. 

Above,  the  rectus  muscles  are  broad  and  attached  to  the  carti- 
lages of  the  fifth,  sixth,  seventh,  and  eighth  ribs  and  to  the  sides  of 
the  ensiform  cartilage.  Below,  they  become  narrow  and  are  attached 
to  the  symphysis  and  crest  of  the  pubes.  The  recti  are  marked  by 
several  transverse  fibrous  intersections,  which  are  united  to  the  ante- 
rior layer  of  the  sheath  of  this  muscle,  but  not  to  the  posterior;  they 
are  usually  three  in  number,  two  above  the  umbilicus  and  one  below. 

The  Aponeuroses  of  the  external  and  internal  oblique  and 
transversalis  are  blended  with  each  other  along  the  outer  border  of 


Fig.  89. — Transverse  Section  of  the  Abdomen  Above  the  Semilunar 
Fold  of  Douglas.  AA,  anterior  .layer  of  the  split  aponeurosis  of  the 
oblique  and  transversalis  muscles — anterior  layer  of  sheath  of  the  rectus; 
C,  descending  colon;  EO,  external  oblique  muscle;  ES,  erector  spinas 
muscle;  I,  intestine  suspended  by  the  mesentery;  10,  internal  oblique 
muscle;  E,  kidney;  LD,  latissimus  dorsi  muscle;  LS,  linea  semilunaris; 
M,  mesentery  (suspends  small  intestine  to  vertebral  column);  P,  psoas 
muscle;  P,  P,  P,  peritoneum  lining  inner  aspect  of  abdominal  wall; 
PA,  posterior  layer  of  split  aponeurosis  of  the  oblique  and  transverse 
muscles — posterior  layer  of  sheath  of  rectus;  QL,  quadratus  lumborum 
muscle;  R,  rectus  muscle;  T,  T,  transversalis  tascia;  TR,  transversalis 
muscle. 


Fig.  90. — Transverse  Section  of  the  Abdomen  Below  the  Semilunar 
Fold  of  Douglas,  Showing  the  Entire  Aponeurosis  Passing  in  Front  of 
the  Rectus  Muscle.  A,  aponeurosis  of  the  abdominal  muscles  (oblique 
and  transversalis),  passing  undivided  in  front  of  the  rectus.  For  ex- 
planation of  letters  see  Fig.  S9. 


ABDOMEN.  227 

the  rectus  muscle.  Here,  corresponding  to  the  linea  semilunaris, 
they  form  one  aponeurotic  layer.  At  the  outer  border  of  the  rectus 
the  conjoined  aponeurosis  splits  into  two  layers, — an  anterior  and 
a  posterior, — and  these  include  the  rectus  between  them,  one  pass- 
ing in  front  of  the  muscle  and  the  other  behind  it,  and  both  joining 
again  with  each  other,  between  the  recti,  in  the  middle  line,  to  form 
the  linea  alba.  This  disposition  of  the  aponeurosis  and  sheath  of 
the  rectus  is  very  simple  and  holds  for  the  upper  three-fourths  of 
the  muscle.  Corresponding  to  the  lower  fourth  of  the  rectus,  the 
whole  aponeurotic  layer,  without  splitting,  passes  in  front  of  the 
muscle;  so  that  this  lower  fourth  of  the  rectus,  upon  its  posterior 
aspect,  is  without  a  proper  sheath  and  is  covered  only  by  the  general 
fascia  transversalis.  Upon  the  posterior  aspect  of  the  rectus,  where 
the  posterior  layer  of  the  sheath  terminates,  it  presents  a  sharp, 
curved  edge:   the  semilunar  fold  of  Douglas. 

The  Fascia  Transversalis.  —  Lining  the  inner  surface  of  the 
transversalis  muscle  and  continued  over  the  whole  internal  surface 
of  the  abdomen  is  a  strong  fascia,  the  fascia  transversalis.  Above, 
this  fascia  is  thin  and  lines  the  abdominal  surface  of  the  diaphragm. 
In  front  and  upon  the  sides  it  lines  the  internal  aspect  of  the  mus- 
cles, etc.,  that  form  the  antero-lateral  wall  of  the  abdomen.  In  the 
inguinal  region  it  is  rather  thicker.  Behind,  upon  the  posterior  wall 
of  the  abdomen  the  fascia  covers  the  psoas  and  cpiadratus  lumborum 
muscles,  forming  in  this  situation  the  anterior  layer  of  the  lumbar 
fascia.  This  portion  of  the  fascia,  being  traced  downward,  is  seen 
to  invest  the  psoas  and  iliacus  muscles  and  is  attached  to  the  inner 
lip  of  the  crest  of  the  ilium  and  to  Poupart's  ligament  except  where 
the  femoral  vessels  escape,  under  the  ligament,  into  the  thigh.  As 
the  psoas  and  iliacus  muscles  pass  out  of  the  abdomen,  under  Pou- 
part's ligament,  into  the  thigh,  the  fascia  accompanies  and  invests 
them.  That  portion  of  the  fascia  which  covers  and  invests  the  psoas 
and  iliacus  muscles,  both  within  the  abdomen  and  also  in  the  thigh, 
under  Poupart's  ligament,  is  known  as  the  fascia  iliaca.  The  fascia 
also  dips  down  into  the  true  pelvis,  lining  its  internal  wall,  muscles, 
etc.,  providing  more  or  less  complete  sheaths  to  the  pelvic  viscera  and 
is  here  known  as  the  pelvic  fascia.  All  these  fasciae,  though  having 
different  names,  are  simply  parts  of  the  general  transversalis  fascia 
or  fascia  endoabdominalis. 

The  Parietal  Peritoneum. — The  whole  interior  of  the  abdominal 
cavity  is  lined  by  the  parietal  layer  of  the  peritoneum.     Between 


228  ABDOMEN  AND  BACK. 

this  parietal  layer  of  the  peritoneum  and  the  transversalis  fascia 
there  is  a  layer  of  loose  connective  tissue  which  contains  a  consid- 
erable quantity  of  fat.     This  is  the  subperitoneal  connective  tissue. 

Through  an  incision  in  the  anterior  abdominal  wall  placed  just 
to  the  left  of  the  middle  line,  we  may  study  the  round  ligament  of 
the  liver.  This  structure  is  the  remains  of  the  foetal  umbilical  vein 
and  reaches  from  the  posterior  aspect  of  the  navel  upward  and  to 
the  right  as  far  as  the  under  surface  of  the  liver.  A  fold  of  the 
parietal  peritoneum,  which  is  reflected  from  the  anterior  abdominal 
wall  around  the  round  ligament,  is  called  the  falciform  ligament. 

Accompanying  the  round  ligament  of  the  liver  from  the  region 
of  the  umbilicus  are  several  veins;  one,  the  largest,  enters  the  portal 
system,  and  thus  establishes  a  communication  between  the  veins  of 
the  wall  of  the  abdomen  and  the  portal  circulation. 

Eeaching  downward,  in  the  middle  line  from  the  umbilicus  to 
the  summit  of  the  bladder,  is  the  urachus.  This  is  a  musculo-nbrous 
cord, — the  remains  of  the  foetal  allantois, — and  may  be  found  more 
or  less  pervious  in  the  child  or  adult;  so  that  a  communication  may 
thus  exist  between  the  umbilicus  and  the  bladder.  As  the  parietal 
peritoneum  which  lines  the  posterior  surface  of  the  anterior  abdom- 
inal wall,  passes  over  the  urachus,  it  is  raised  in  the  form  of  a  distinct 
longitudinal  fold:   the  plica  vesico-umbilicalis  media. 

The  Deep  Vessels  of  the  Abdominal  Wall. — Between  the  layers 
of  the  muscles  of  the  abdomen  the  deep  vessels  of  the  abdominal 
wall  ramify.  Above  are  found  the  terminal  branches  of  the  internal 
mammary,  the  superior  epigastric,  and  the  musculo-phrenic.  The 
superior  epigastric  is  continued  from  the  thorax,  through  the  open- 
ing in  the  diaphragm,  between  its  costal  and  sternal  portions;  it 
pierces  the  posterior  layer  of  the  sheath  of  the  rectus,  supplies  this 
muscle  and  gives  off  branches  which  perforate  the  muscle  and  the 
anterior  layer  of  its-  sheath  to  supply  the  subcutaneous  tissue  and 
skin  of  the  abdomen.  It  anastomoses  with  branches  of  the  superficial 
epigastric  and  deep  (inferior)  epigastric. 

Below,  the  deep  epigastric  and  deep  circumflex  iliac,  which  are 
derived  from  the  external  iliac,  are  encountered;  these  are  given 
off  just  before  this  vessel  passes  under  Poupart's  ligament  to  become 
the  femoral. 

The  deep  epigastric  is  directed  upward  and  inward  toward  the 
umbilicus,  resting  upon  the  posterior  surface  of  the  rectus,  be- 
tween the  transversalis  fascia  and  the  parietal  peritoneum,  and 
enters  the  substance  of  this  muscle  below  the  semilunar  fold  of 


Fig.  91.— The  Regions  of  the  Abdomen  as  Indicated  by  Two  Transverse 
Lines  drawn  through  the  Tips  of  the  Cartilages  of  the  Tenth  Ribs  and  the 
Anterior  Superior  Iliac  Spines  and  Two  Oblique  Lines  drawn  from  the  Tips 
of  the  same  Cartilages  down  to  the  Pubic  Spines.  The  liver  and  gall-bladder 
are  indicated  in  orange,  stomach  and  duodenum  in  red  (dotted  lines  repre- 
sent that  part  of  the  duodenum  which  lies  behind  the  stomach).  The  pan- 
creas  and   colon   are   indicated   in   blue,    the   kidneys   in   green. 


ABDOMEN.  229 

Douglas,  supplying  it  and  anastomosing  with  the  end  branches  of 
the  superior  epigastric.  Some  branches  from  this  vessel  pierce  the 
anterior  layer  of  the  sheath  of  the  rectus  muscle  and  ramify  in  the 
fatty  layer  beneath  the  skin. 

The  deep  circumflex  iliac  passes  upward  and  outward  beneath 
and  parallel  with  Poupart's  ligament  toward  the  anterior  superior 
iliac  spine;  it  then  runs  along  the  crest  of  the  ilium  and  after 
piercing  the  transversalis  fascia  is  distributed  to  the  muscles  of  the 
abdomen. 

From  behind  come  the  abdominal  branches  of  the  lumbar  ar- 
teries: usually  four.  They  pass  forward  between  the  muscles  and 
anastomose  with  the  branches  of  the  musculo-phrenic,  superior  epi- 
gastric, the  deep  epigastric,  and  the  deep  circumflex  iliac.  These 
arteries  are  all  accompanied  by  their  corresponding  veins. 

The  Regions  of  the  Abdomen. — The  surface  of  the  abdomen  may 
be  marked  off  into  areas  by  several  imaginary  lines  which  intersect 
each  other.  Two  of  these  are  transverse,  the  upper  passing  through 
the  tips  of  the  tenth  ribs,  the  lower  through  the  highest  points  of 
the  iliac  crests.  These  are  crossed  by  two  lines  which  pass  from  the 
tip  of  the  tenth  rib  of  either  side  downward  and  inward  to  the  pubic 
spine. 

Above  the  upper  transverse  line  is  the : — 

(a)  Eegio  epigastrica; 
between  the  two  transverse  lines  is  the 

(b)  Eegio  mesogastrica; 

and  below  the  lower  transverse  line  is  the 

(c)  Eegio  hypogastrica. 

The  regio  epigastrica  is  subdivided  into  three  portions : — 

1.  Eegio  epigastrica  proper. 

2.  Eegio  hypochondriaca  dextra. 

3.  Eegio  hypochondriaca  sinistra. 

The  regio  mesogastrica  is  subdivided  into  three  portions : — 

1.  Eegio  umbilicalis. 

2.  Eegio  abdominis  lateralis  dextra. 

3.  Eegio  abdominis  lateralis  sinistra. 

The  regio  hypogastrica  is  subdivided  into  three  portions : — 

1.  Eegio  pubica. 

2.  Eegio  inguinalis  dextra. 

3.  Eegio  inguinalis  sinistra. 


230  ABDOMEN  AND  BACK. 

THE  BACK. 

When  we  speak  of  the  back  we  mean  the  whole  posterior  part 
of  the  trunk.  The  back  may  be  divided  into  three  regions:  the 
dorsal,  the  lumbar,  and  the  sacral. 

It  is  better  to  consider  the  back  as  a  whole,  since  these  regions 
merge  directly  into  each  other  without  any  definite  dividing  line. 

Above  the  back  is  limited  by  the  vertebra  prominens  and  below 
by  the  tip  of  the  coccyx.  The  dorsal  portion  corresponds  to  the 
chest,  and  includes  the  dorsal  vertebra?  and  the  ribs,  the  scapulas 
and  the  muscles  of  this  region.  The  lumbar  portion  forms  the  poste- 
rior wall  of  the  abdominal  cavity,  and  includes  the  five  lumbar  ver- 
tebras and  the  thick  mass  of  muscle  on  either  side  which  fills  in  the 
space  between  the  last  rib  and  crest  of  the  ilium. 

The  sacral  region  corresponds  to  the  posterior  wall  of  the  true 
pelvic  cavity  and  includes  the  sacrum  and  the  coccyx. 

In  the  middle  of  the  back  there  is  a  longitudinal  furrow  in 
which  the  spinous  processes  of  the  vertebrae,  from  the  seventh  cer- 
vical, vertebra  prominens,  above,  to  the  sacrum  below,  may  be  dis- 
tinctly felt;  those  which  correspond  to  the  sacrum  are  less  prominent. 

To  either  side  of  this  median  furrow  there  is  a  prominent  mass 
formed  by  the  longitudinal  muscles  of  the  back.  These  masses  ex- 
tend from  the  sacrum  to  the  occiput,  and,  the  more  pronounced  they 
are,  the  deeper  is  the  median  groove. 

In  the  dorsal  region,  on  either  side,  are  the  scapulae — shoulder- 
blades.  These  bones  are  triangular  in  shape  and  are  located  between 
the  first  and  eighth  ribs  toward  the  outer  part  of  the  thorax.  The 
inner  or  vertebral  border  of  the  scapula  is  nearly  parallel  with  the 
spinous  processes  of  the  vertebrae  when  the  arm  hangs  by  the  side. 
This  bone  is  freely  movable  and  its  position  varies  according  to  the 
position  of  the  upper  extremity.  The  spine  of  the  scapula  is  felt 
beneath  the  skin  and  may  be  traced  outward  and  upward;  its  outer 
end,  which  is  prolonged  outward  and  flattened  from  above  down- 
ward, is  called  the  acromion  process  and  overhangs  the  shoulder- 
joint,  articulating  with  the  outer  end  of  the  clavicle.  The  lower 
extremity  of  the  scapula,  the  angle,  corresponds  to  the  eighth  rib, 
and  is  a  surgical  landmark  of  some  value. 

The  skin  and  subcutaneous  connective  tissue  of  the  back  is 
continuous  with  the  corresponding  layers  of  the  adjoining  parts  of 
the  trunk.  The  subcutaneous  tissue  is  rather  firm  and  fibrous  and 
contains  a  varying  amount  of  fatty  tissue.     The  deep  fascia  of  the 


BACK.  231 

back  is  a  strong,  dense,  fibrous  layer  which  covers  in  the  superficial 
muscles;  it  is  attached  in  the  middle  line  to  the  spinous  processes 
of  the  vertebras  and  may  be  traced  upward,  upon  the  trapezius  mus- 
cle, as  far  as  the  occipital  bone,  to  which  it  is  attached.  In  the  dorsal 
region  it  is  attached  to  the  subcutaneous  surface  of  the  spine  of  the 
scapula.  Below  it  is  attached  to  the  crest  of  the  ilium  and  to  the 
sacrum. 

The  Muscles  of  the  Back  are  numerous  and  may  be  divided  into 
several  layers. 

First  Layer  of  Muscles. — Trapezius  and  latissimus  dorsi. 

The  Trapezius  is  a  broad,  flat  muscle,  one  on  either  side;  to- 
gether they  are  lozenge-shaped  and  occupy  the  dorsal  and  cervical 
regions.  Each  muscle  arises  from  the  superior  curved  line  of  the 
occipital  bone,  from  the  ligamentum  nuchas,  which  corresponds  to 
the  spinous  processes  of  the  cervical  vertebras,  and  from  the  spinous 
processes  of  all  the  dorsal  vertebras.  From  this  extensive  origin  the 
muscle  of  each  side  is  attached  as  follows:  Those  fibers  which  arise 
from  the  occipital  bone  pass  downward,  outward,  and  forward,  and 
are  attached  to  the  upper  surface  of  the  outer  one-third  of  the  clav- 
icle; those  from  the  dorsal  and  cervical  vertebras  converge  and  are 
attached  to  the  whole  length  of  the  upper  border  of  the  spine  of 
the  scapula.  That  portion  of  the  muscle  which  corresponds  to  the 
lower  cervical  and  upper  dorsal  vertebrae  shows  an  aponeurotic  origin, 
which,  together  with  that  of  the  opposite  side,  is  oval  in  shape. 

The  Latissimus  Dorsi  is  broad,  triangle-shaped,  and  flat,  and 
occupies  the  lumbar  and  lower  dorsal  regions,  being  partly  over- 
lapped by  the  trapezius. 

It  arises  by  aponeurotic  fibers  from  the  spinous  processes  of  the 
five  or  six  lower  dorsal  and  the  lumbar  vertebras.  Below  the  aponeu- 
rotic origin  of  the  latissimus  dorsi  is  intimately  blended  with  the 
aponeurosis  that  covers  the  erector  spinas;  the  muscle  also  arises 
from  the  back  part  of  the  outer  lip  of  the  crest  of  the  ilium  and  by 
three  or  four  slips  from  the  external  surface  of  the  lower  ribs.  From 
this  extensive  origin  the  fibers  all  converge,  and  at  the  angle  of  the 
scapula  they  form  a  thick,  flat,  fleshy  muscle,  which,  making  a  half- 
turn  upon  itself,  passes  upward,  in  front  of  the  teres  major,  and  is 
attached  by  a  narrow,  flat,  aponeurotic  tendon  to  the  inner  lip  of 
the  bicipital  groove  of  the  humerus.  The  tendon  of  the  latissimus 
dorsi  and  the  teres  major  form  the  lower  border  of  the  posterior 
wall  of  4he  axilla. 


232  ABDOMEN  AND  BACK. 

Second  Latee  of  Muscles: 

Levator  anguli  scapulas. 

Khomboideus  1 

{  Minor. 

The  Levator  Anguli  Scapulce  is  located  in.  the  side  of  the  neck 
and  the  upper  dorsal  region.  It  arises  by  tendinous  slips  from  the 
tubercles  on  the  transverse  processes  of  the  four  upper  cervical  ver- 
tebras; passing  down  the  side  of  the  neck,  it  is  attached  to  the  upper 
part  of  the  inner,  or  vertebral,  border  of  the  scapulas. 

The  Rhomboids  are  two  flat  muscles  placed  one  above  the  other, 
both  lying  upon  the  same  plane  and  really  forming  one  broad,  flat 
muscle.  Internally  they  are  attached  to  the  spinous  processes  of 
the  last  cervical  and  four  or  five  upper  dorsal  vertebras,  and  exter- 
nally to  the  vertebral  border  of  the  scapula. 

Third  Later  of  Muscles. — Splenius;  serratus  posticus,  supe- 
rior and  inferior. 

The  Splenius  is  located  in  the  back  of  the  neck  and  upper  dorsal 
region,  reaching  from  the  occiput  downward  as  far  as  the  sixth  dorsal 
vertebras  below. 

The  Serratus  Posticus. — The  superior  and  inferior  are  two  thin, 
flat  muscles,  the  superior  being  located  in  the  upper  dorsal  region, 
the  inferior  in  the  lower  dorsal  and  lumbar  regions. 

The  Muscles  of  the  Fourth  Layer  are  numerous  and  have 
a  longitudinal  direction,  reaching  upward,  alongside  of  the  spinal 
column,  from  the  sacrum  as  far  as  the  occiput.  The  muscles  of  this 
group,  except  the  erector  spinas,  are  of  but  little  importance  sur- 
gically. 

The  Erector  Spinas  below,  in  the  lumbar  region,  forms  a  large 
musculo-tendinous  mass,  which  fills  in  the  space  on  either  side  of 
the  lumbar  part  of  the  spinal  column,  being  superimposed  upon  the 
quadratus  lumborum  in  this  region.  From  the  lumbar  region  the 
erector  spinas  is  continued  upward  into  the  dorsal  region.  In  the 
dorsal  region  this  muscle  divides  into  a  number  of  processes,  each 
of  which  receives  a  different  name  and  is  described  as  a  separate 
muscle.  The  erector  spinas  below,  in  the  lumbar  region,  is  covered 
by  a  dense  aponeurotic  structure:  the  posterior  layer  of  the  lumbar 
fascia.  The  muscle  arises  from  the  back  part  of  the  iliac  crest  and, 
through  its  aponeurosis,  from  the  posterior  surface  of  the  sacrum 
and  from  the  spinous  processes  of  the  lumbar  and  two  or  three  lower 


BACK  233 

dorsal  vertebras.  The  erector  spinas  is  included  between  the  poste- 
rior and  middle  layers  of  the  lumbar  fascia.  The  quadratus  lum- 
borum  lies  beneath  the  erector  spinas. 

In  the  lumbar  region  the  erector  spinas  forms  a  well-marked 
muscular  mass,  and  its  outer  edge  is  an  important  guide  in  cutting 
down  upon  the  kidney. 

The  Muscles  of  the  Fifth  Layer  are  numerous,  and  are  made 
up,  for  the  most  part,  of  longitudinal  strips  that  connect  adjoining 
vertebras  to  each  other.  They  are  all  more  or  less  continuous  with 
each  other,  but  receive  different  names  in  different  regions.  They 
are  lodged  in  the  groove  upon  either  side  of  the  spinous  processes, 
and  extend  from  the  sacrum  to  the  occiput. 

The  Quadratus  Lumborum  is  really  a  muscle  of  the  abdomen, 
forming  part  of  its  posterior  wall ;  it  is  quadrilateral  in  shape,  broad, 
and  thick.  It  fills  in  the  space  on  either  side  of  the  spinal  column 
from  the  last  rib  to  the  crest  of  the  ilium.  It  is  broader  below  at 
its  attachment  to  the  crest  of  the  ilium  than  above  at  its  insertion 
into  the  last  rib.  Its  outer  border  is  free  and  lies  more  external  than 
that  of  the  erector  spinas,  and  forms  an  important  surgical  guide. 

The  muscle  arises  by  aponeurotic  fibers  from  the  upper  part 
of  the  ilio-lumbar  ligament  and  from  the  adjacent  part  of  the  crest 
of  the  ilium  for  a  distance  of  about  two  inches.  Prom  this  origin 
the  muscle  passes  upward  and  is  inserted  into  the  inner  half  of  the 
lower  border  of  the  last  rib  and,  by  fleshy  slips,  to  the  transverse 
processes  of  the  four  upper  lumbar  vertebras. 

The  muscle  is  inclosed  between  the  middle  and  anterior  layers 
of  the  lumbar  fascia,  and  lies  directly  beneath  the  erector  spinas, 
from  which  it  is  separated  by  the  middle  layer  of  the  lumbar  fascia. 

The  Lumbar  Fascia. — In  the  lumbar  region  there  is  a  strong 
aponeurotic  structure  called  the  lumbar  fascia;  it  is  through  this 
fascia  that  the  transversalis  muscle  is  connected  with  the  spine. 
The  lumbar  fascia  is  usually  described  as  consisting  of  three  layers 
(see  Fig.  89).  The  anterior  layer  is  rather  thin,  covers  the  front 
surface  of  the  quadratus  lumborum  muscle,  and  is  attached  inter- 
nally to  the  anterior  aspect  of  the  transverse  processes  of  the  lumbar 
vertebras;  above,  this  layer  of  the  fascia  is  attached  to  the  lower 
border  of  the  last  rib,  where  it  constitutes  the  ligamentum  arcuatum 
externum.  The  middle  layer  of  the  lumbar  fascia  is  strong,  is  at- 
tached to  the  apices  of  the  transverse  processes  of  the  lumbar  ver- 
tebras, and  is  placed  between  the  quadratus  lumborum  and  erector 


234  ABDOMEN  AND  BACK. 

spinas  muscles.  The  posterior  layer  of  the  lumbar  fascia  is  attached 
to  the  apices  of  the  spinous  processes  of  the  lumbar  vertebrae;  it 
forms  the  posterior  aponeurotic  covering  of  the  erector  spinse,  and 
is  blended  with  the  aponeurosis  of  origin  of  the  latissimus  dorsi.  At 
the  outer  border  of  the  quadratus  lumborum  the  three  layers  of  the 
lumbar  fascia  unite  to  form  a  single  aponeurotic  layer,  through  which 
the  transversalis  muscle  is  connected  with  the  spinal  column. 

The  Psoas  and  Iliacus  Muscles. — In  the  back  of  the  abdomen, 
lying  one  upon  either  side  of  the  spinal  column,  is  the  psoas  muscle. 
It  arises  by  slips  from  the  transverse  processes  and  bodies  of  the  last 
dorsal  and  the  lumbar  vertebras,  and  passing  downward  joins  with 
the  iliacus. 

The  iliacus  muscle  occupies  the  iliac  fossa,  taking  its  origin 
there,  and,  together  with  the  psoas,  passes  out  of  the  abdomen  under 
Poupart's  ligament  to  be  attached  to  the  lesser  trochanter  of  the 
femur  and  to  the  surface  of  the  bone  immediately  below  this. 

The  psoas  and  iliacus  are  covered  by  a  fascia,  the  iliac  fascia. 
This  is  simply  a  part  of  the  general  transversalis  fascia  of  the  ab- 
domen. That  part  which  covers  the  psoas  muscle  is  thickened  above, 
where  it  is  known  as  the  ligamentum  arcuatum  internum;  laterally, 
beyond  the  edge  of  the  psoas  muscle,  this  fascia  is  continuous  with 
that  which  covers  the  quadratus  lumborum:  the  anterior  layer  of 
the  lumbar  fascia.  The  iliac  fascia  covers  the  iliacus  muscle  also, 
and  is  attached  to  the  crest  of  the  ilium  and  the  brim  of  the  pelvis, 
and  to  Poupart's  ligament  except  where  the  femoral  vessels  pass 
down  into  the  thigh.  In  this  situation  the  fascia  is  continued  down- 
ward, under  Poupart's  ligament,  behind  the  vessels  into  the  thigh, 
covering  the  anterior  surface  of  the  psoas-iliacus  muscle. 

The  parietal  peritoneum  is  spread  out  over  the  inner  surface 
of  the  posterior  wall  of  the  abdomen.  The  kidney,  incased  in  its 
capsule  of  fat,  lies  between  this  layer  of  the  peritoneum  and  the 
fascia  which  covers  the  quadratus  lumborum  muscle. 

The  Spinal  Column,  etc. — The  spinal  column  is  made  up  of  the 
vertebrae  and  intervertebral  pads,  the  sacrum,  and  the  coccyx;  it  is 
located  at  a  considerable  depth  from  the  surface  of  the  body.  The 
spinal  column  gives  solidity,  combined  with  flexibility,  to  the  trunk, 
and  furnishes  a  canal  to  contain  and  protect  the  spinal  cord. 

We  may  palpate  the  body  of  the  first  cervical  vertebra,  the  atlas, 
through  the  mouth,  its  anterior  tubercle  lying  just  behind  the  soft 
palate;  those  vertebras  which  lie  below  this  down  as  far  as  the  fiftk 


BACK.  235 

cervical  may  also  be  palpated  through  the  mouth.  Lower  in  the 
neck  and  in  the  dorsal  region  palpation  of  the  bodies  of  the  vertebrae 
is  impossible.  The  bodies  of  the  lumbar  vertebrae  can  be  felt  through 
the  abdomen,  especially  in  thin  persons.  The  sacrum  and  coccyx 
may  be  palpated  through  the  rectum. 

The  laminae  meet  behind,  in  the  middle  line,  to  form  the  spinous 
processes  and  to  complete  the  canal  which  contains  the  spinal  cord. 

In  the  cervical  and  lumber  regions  the  spaces  between  the 
laminae  are  broad,  and  a  knife-blade  might  easily  be  introduced 
through  these  into  the  spinal  canal.  This  could  not  be  so  readily 
done  in  the  dorsal  region,  however,  where  the  laminae  and  spines 
overlap  each  other  like  the  shingles  on  a  roof. 

The  spaces  between  the  laminae  are  occupied  by  the  ligamenta 
subflava,  which  serve  to  complete  the  canal  and  even  it  out  upon 
its  inner  aspect. 

The  bodies  of  the  vertebrae  are  joined  to  each  other  by  the  ante- 
rior and  posterior  common  ligaments;  the  posterior  common  liga- 
ment, besides  connecting  the  bodies  of  the  vertebrae  with  each  other, 
also  serves  to  even  out  the  irregularities  upon  the  internal  aspect  of 
the  canal.  The  spines  of  the  vertebrae  are  connected  with  each  other 
by  ligaments:   the  interspinous  and  the  supraspinous. 

The  spinal  column  presents  three  curves  in  the  sagittal  direc- 
tion, antero-posterior,  and  one  lateral  with  the  concavity  toward  the 
left  (aorta). 

Fractures  of  the  spine,  usually  involve  the  fifth  and  sixth  cer- 
vical, last  dorsal,  and  first  lumbar  vertebrae,  and  are  usually  caused 
by  indirect  violence,  the  curved  parts  of  the  spine  being  bent  beyond 
the  limit  of  their  elasticity. 

The  spinal  canal  is  widest  in  the  neck  and  triangular  upon  sec- 
tion; narrower  in  the  dorsal  region  and  circular  upon  section.  It  is 
narrowest  at  the  level  of  the  ninth  dorsal.  From  the  eleventh  dorsal 
it  becomes  wider  again.  In  the  sacrum  it  is  flattened  from  before 
backward  and  terminates  upon  the  posterior  surface  of  this  bone. 

The  spinal  canal  shows  a  series  of  openings — intervertebral — 
upon  either  side,  just  behind  the  bodies,  for  the  passage  of  nerves 
and  vessels  to  and  from  the  canal.  The  contents  of  the  canal  are 
well  protected.  It  is  an  uncommon  accident  for  an  instrument  to 
penetrate  into  the  canal,  and  unusual  force  is  required  to  injure  the 
cord  inclosed  within  these  bony  walls. 

Contained  within  the  canal  is  the  spinal  cord,  which  is  much 


236  ABDOMEN  AND  BACK. 

smaller  and  shorter  than  the  canal;  the  spinal  cord  commences  at 
the  upper  border  of  the  posterior  arch  of  the  atlas,  where  it  is  con- 
tinuous with  the  medulla,  and  terminates  below  in  the  conus  ter- 
minals on  a  level  with  the  lower  border  of  the  first  lumbar  vertebra. 
From  the  conus  terminalis  the  cord  is  prolonged  still  farther  down- 
ward as  the  filum  terminale. 

The  spinal  cord,  as  it  lies  within  the  canal,  is  inclosed  by  the 
dura  and  pia  mater.  The  dura  mater  of  the  spinal  canal  is  continu- 
ous with  the  dura  mater  that  lines  the  interior  of  the  skull,  and  is 
adherent  to  the  margin  of  the  foramen  magnum.  Here  it  splits  into 
two  layers,  the  external  of  which  is  applied  to  the  inner  aspect  of  the 
spinal  canal  as  a  lining  membrane,  periosteum,  whereas  the  other, 
the  inner  layer,  forms  a  loose,  sack-like  envelope  for  the  cord,  the 
dura  mater  proper,  and  is  continued  all  the  way  down  to  the  coccyx, 
where  it  is  blended  with  the  periosteum  of  that  bone.  Between  these 
two  layers  there  is  a  space  in  which  veins  and  arteries  ramify  and 
into  which  hemorrhage  may  take  place.  Each  nerve,  at  its  exit  from 
the  spinal  canal,  has  prolonged  upon  it  a  tubular  process,  which  is 
derived  from  the  dura  and  pia  mater. 

Beneath  this  dura  mater  sheath  is  the  pia  mater,  a  reticular 
structure  like  that  which  invests  the  brain;  the  outer  surface  of  the 
pia  is  known  as  the  arachnoid,  and  the  inner,  which  is  applied  di- 
rectly to  the  surface  of  the  cord,  is  known  as  the  pia  mater  proper 
and  carries  the  vessels  which  penetrate  into  the  substance  of  the  cord 
to  supply  it. 

Between  the  two  surfaces  of  the  pia  there  is  a  space,  which  is 
called  the  subarachnoid  space,  and  which  is  subdivided,  cut  up,  by 
numerous  trabecular  into  a  net-work  of  small  spaces.  In  the  sub- 
arachnoid space,  between  the  two  layers  of  the  pia,  the  cerebro- 
spinal fluid  is  found.  From  the  pia  mater  laterally,  between  the 
roots  of  the  nerves,  there  arises  a  longitudinal  septum  which  is  at- 
tached to  the  inner  surface  of  the  dura  mater  by  a  number  of  proc- 
esses. The  line  of  origin  from  the  pia  is  continuous.  The  line  of 
attachment  to  the  dura  mater  is  interrupted.  This  is  known  as  the 
ligamentum  dentatum. 

The  surfaces  of  the  dura  and  the  pia  mater  (arachnoid)  are  not 
joined  to  each  other  except  for  occasional  strands  of  connective  tis- 
sue that  unite  them  here  and  there.  The  space  between  the  dura 
and  pia  mater  is  known  as  the  subdural  space. 


SURGICAL  ANATOMY  OF  THE  STOMACH.  237 

Each  nerve-root  is  provided  with  an  envelope  consisting  of  a 
process  of  the  pia  and  dura. 

Arteries  that  supply  the  cord  consist  of  branches  from  the  ver- 
tebral, intercostals,  lumbar,  and  lateral  sacral;  all  along  the  spinal 
column  these  vessels  pass  through  the  intervertebral  foramina  to  sup- 
ply the  coverings  and  the  cord. 

Veins,  in  the  form  of  plexuses,  are  found  on  the  front  and  back 
of  the  cord,  within  the  canal,  between  the  two  layers  of  the  dura, 
or,  better,  between  the  dura  proper  and  the  periosteum. 

THE  STOMACH. 

The  Surgical  Anatomy  of  the  Stomach. — The  stomach  is  a  pear- 
shaped,  pouched  portion  of  the  alimentary  canal  with  a  capacity  of 
from  three  to  four  pints.  It  is  suspended  obliquely  in  the  upper  part 
of  the  abdomen,  upon  the  left  side,  extending  from  the  oesophagus  to 
the  duodenum.  Its  walls  are  thick,  and  consist  of  a  serous,  a  mus- 
cular, a  submucous,  and  a  mucous  membrane  coat. 

The  larger  end  of  the  stomach,  the  cardiac,  is  above  and  toward 
the  left  side;  the  smaller  end,  the  pyloric,  is  below  and  toward  the 
right  side. 

The  oesophageal  opening  is  called  the  cardiac,  and  the  opening 
into  the  duodenum,  the  pyloric  orifice.  The  dilated  left  end  of  the 
stomach — i.e.,  that  part  to  the  left  of  the  oesophageal  opening — is 
called  the  fundus;  the  middle  part,  the  body;  and  the  right,  rather 
constricted  portion,  the  pylorus. 

The  stomach  presents  an  upper  or  right  border,  the  lesser  curva- 
ture, which  is  about  four  inches  long,  and  a  lower  or  left  border,  the 
greater  curvature,  which  is  about  three  times  as  long  as  the  lesser 
curvature.  It  has  an  anterior  wall  directed  forward  and  upward  and 
a  posterior  wall  which  is  directed  backward  and  downward. 

The  adult  stomach,  moderately  distended,  measures  in  its  long- 
est diameter  from  ten  to  twelve  inches;  from  the  greater  to  the 
lesser  curvature,  four  to  five  inches;  and  from  the  anterior  to  the 
posterior  wall  about  three  and  one-half  inches.  When  the  stomach 
is  empty  the  first  and  second  diameters  are  diminished  and  the  third 
disappears,  as  the  walls  come  into  contact  with  each  other.  In  this 
condition  the  mucosa  is  thrown  into  numerous  folds  and  ruga?. 

The  opening  between  the  pylorus  and  the  duodenum  is  indi- 
cated by  a  well-marked  thickening  of  the  wall  of  the  stomach,  which 


238  ABDOMEN  AND  BACK. 

may  be  felt  from  without;  it  is  made  up  of  circular  muscular  fibers, 
which  act  as  a  sphincter  and  which  serve  to  shut  off  the  cavity  of 
the  stomach  from  that  of  the  duodenum. 

The  stomach  is  situated  in  the  left  hypochondriac  and  the  epi- 
gastric regions;  about  five-sixths  part  of  the  organ  lies  to  the  left 
of  the  middle  line,  the  pyloric  end  lying  to  the  right  of  the  middle 
line.  The  cardiac  orifice  is  located  one  inch  below  the  diaphragm, 
to  the  left  of  the  body  of  the  eleventh  dorsal  vertebra,  and  at  a  depth 
of  11  cm.  from  the  front  wall  of  the  abdomen,  on  a  line  directly 
behind  the  articulation  of  the  seventh  left  costal  cartilage  with  the 
sternum.  The  pyloric  orifice  lies  to  the  right  and  a  little  below  the 
ensif  orm  cartilage  and  nearer  the  anterior  wall  of  the  abdomen.  The 
direction  of  a  line  drawn  from  the  cardiac  orifice  to  the  pyloric  orifice 
would  be  downward  and  to  the  right.  The  fundus  of  the  stomach 
reaches  upward  as  high  as  the  level  of  the  fifth  costal  cartilage,  and 
is  separated  from  the  base  of  the  left  lung  by  the  diaphragm.. 

The  anterior  surface  of  the  stomach,  toward  the  left,  is  in  rela- 
tion with  the  seventh,  eighth,  and  ninth  ribs,  the  diaphragm  being 
interposed;  the  pyloric  end  and  upper  part  of  the  anterior  surface 
of  the  stomach  are  covered  by  the  left  lobe  of  the  liver.  Below  the 
stomach,  along  its  great  curvature  and  attached  to  it  by  the  so-called 
gastro-colic  ligament,  is  the  transverse  colon. 

A  triangular  area  of  the  anterior  wall  of  the  stomach — near  the 
left  free  border  of  the  ribs — is  in  direct  relation  with  the  anterior 
abdominal  wall,  and  is  here  accessible  for  operation.  The  base  of 
this  triangular  space  is  indicated  upon  the  surface  of  the  abdomen 
by  a  transverse  line,  which  corresponds  to  the  transverse  colon  and 
greater  curvature  of  the  stomach  and  which  is  drawn  through  the  tip 
of  the  tenth  rib  (costal  cartilage)  of  either  side.  The  other  lines  of 
the  triangle  are,  upon  the  left,  the  free  border  of  the  ribs,  and,  upon 
the  right  side,  a  line  corresponding  to  the  anterior  thin  edge  of  the 
left  lobe  of  the  liver,  which  is  drawn  from  the  tip  of  the  tenth  right 
costal  cartilage  to  the  tip  of  the  eighth  left  costal  cartilage. 

Behind  the  stomach  lie  the  pancreas,  with  the  splenic  vessels 
passing  along  its  upper  border,  the  upper  part  of  the  left  kidney 
and  suprarenal  capsule,  and,  toward  the  left,  the  spleen. 

Behind  the  pyloric  end  of  the  stomach  are  the  duodenum,  portal 
vein  and  common  bile-duct,  head  of  the  pancreas  and  first  lumbar 
vertebra,  crura  of  the  diaphragm,  aorta  with  the  cceliac  axis,  solar 
sympathetic  plexus,  thoracic  duct,  vena  cava  inferior,  etc. 


SURGICAL  ANATOMY  OF  THE  STOMACH. 


239 


The  spleen  lies  to  the  left  of  the  stomach  and  rather  behind  it. 
The  gall-bladder  is  in  relation  with  the  pyloric  end  of  the  stomach. 

The  stomach  is  entirely  enveloped  by  the  peritoneum,  which 
forms  its  serous  coat;   above,  extending  between  the  transverse  fis- 


LM 


Fig.  92. — Sagittal  Section  to  Show  the  Arrangement  of  the  Great  and 
Lesser  Omenta,  etc.  OM,  great  omentum;  L,  liver;  LM,  lesser  omentum; 
8,  stomach;  TC,  transverse  colon;  *,  situation  where  the  layers  of  the  great 
omentum  become  fused  to  that  portion  of  the  peritoneum  which  invests  bhe 
transverse  colon,  thus  joining  the  latter  to  the  lower  border  of  the  stomach. 

sure  of  the  liver  and  the  lesser  curvature  of  the  stomach,  the  two 
layers  of  the  peritoneum  join  to  form  the  lesser  omentum,  gastro- 
hepatic  ligament,  between  the  layers  of  which,  toward  its  right  edge, 
the  hepatic  artery,  portal  vein,  and  common  bile-duct  are  located. 


240  ABDOMEN  AND  BACK. 

Below,  at  the  greater  curvature,  the  two  layers  of  peritoneum, 
after  enveloping  the  stomach,  again  join  to  form  the  great  omen- 
tum through  which  the  transverse  colon  is  attached  to  the  greater 
curvature  of  the  stomach.  That  portion  of  the  great  omentum 
which  joins  the  stomach  to  the  transverse  colon  is  called  the  gastro- 
colic ligament.  Toward  the  left,  the  two  layers  of  peritoneum  which 
cover  the  anterior  and  posterior  surfaces  of  the  stomach  also  join 
together  to  form  the  gastro-splenic  omentum,  hut  they  again  sepa- 
rate so  as  to  invest  the  spleen  and  connect  it  with  the  fundus  of 
the  stomach.  Between  the  layers  of  the  gastro-splenic  omentum 
the  vasa  brevia  pass  to  the  fundus  of  the  stomach. 

The  arteries  which  supply  the  stomach  are  derived  from  the 
cceliac  axis,  and  consist  of  large  branches  which  course  along  the 
lesser  and  greater  curvatures;  these  vessels  give  off  large  branches, 
which  ramify  upon  the  anterior  and  posterior  walls  of  the  stomach, 
coursing  from  the  periphery  toward  the  middle  of  each  surface; 
along  the  lesser  curvature,  the  pyloric  artery,  a  branch  of  the  hepatic, 
and  the  gastric  artery  anastomose;  along  the  greater  curvature, 
anastomosing  with  each  other,  are  the  gastro-epiploica  dextra,  from 
the  hepatic,  and  the  gastro-epiploica  sinistra,  from  the  splenic.  The 
vasa  brevia,  from  the  splenic,  ramify  upon  the  left  end,  fundus,  of 
the  stomach. 

The  lymphatics  of  the  stomach  form  a  plexus  of  dilated  lymph- 
spaces  in  the  submucous  layer.  From  these  spaces  the  lymphatic 
vessels  run  toward  the  upper  and  lower  borders  and  toward  the  left 
end  of  the  stomach,  where  they  terminate  in  a  number  of  lymphatic 
nodes  that  are  located  between  the  layers  of  the  lesser  and  greater 
omenta  and  the  gastro-splenic  omentum. 

According  to  the  direction  taken  by  the  lymphatics  that  drain  it, 
the  stomach  may  be  divided  into  three  areas:  the  region  adjoining 
the  lesser  curvature,  the  region  adjoining  the  greater  curvature,  and 
that  corresponding  to  the  fundus. 

First. — The  lymphatic  vessels  that  drain  that  portion  of  the 
stomach  adjacent  to  the  lesser  curvature  terminate  in  a  chain  of 
nodes  that  are  situated  between  the  folds  of  the  lesser  omentum, 
along  the  course  of  the  gastric  artery,  reaching  from  the  pylorus 
upward  and  toward  the  left  as  far  as  the  point  where  the  gastric 
artery  strikes  the  stomach.  Here  they  leave  the  stomach  and  may 
then  be  traced  backward  behind  the  pancreas  to  the  nodes  that  are 
found  adjacent  to  the  cceliac  axis. 


Fig.  93. — Stomach,  showing  Arteries  that  Supply  it,  its  Lymphatics  and 
Adjacent  Lymph-nodes.  Corresponding  to  the  lesser  curvature,  the  lym- 
phatics run  in  a  direction  away  from  the  pylorus  to  terminate  in  the  nodes 
along  this  border  of  the  stomach.  Corresponding  to  the  greater  curvature, 
they  run  toward  the  pylorus  to  communicate  with  the  nodes  below  and  be- 
hind the  pyloric  end  of  the  stomach.  The  lymphatics  of  the  fundus  ter- 
minate in  the  nodes  at  the  hilum  of  the  spleen.  ED,  epiploica  dextra;  E8, 
epiploica  sinistra;  G,  gastric;  GD,  gastro-duodenalis;  H,  hepatic;  P,  pyloric; 
8,   splenic.     Arrows  indicate  direction  of  the  lymph   current. 


OPERATIONS  UPON  THE  STOMACH.  241 

Second. — The  lymphatics  that  drain  the  lower  part  of  the  body 
of  the  stomach,  parts  adjacent  to  the  greater  curvature,  run  from 
the  left  downward  and  toward  the  right,  to  terminate  in  a  chain  of 
nodes  spread  along  the  greater  curvature,  and  below  and  behind  the 
pylorus,  along  the  course  of  the  gastro-epiploica  dextra,  whence  they 
may  also  be  traced  to  the  group  of  nodes  about  the  cceliac  axis. 

Third. — The  lymphatics  that  drain  the  lower  end  of  the  oesoph- 
agus and  the  cardiac  end  of  the  stomach,  fundus,  etc.,  pass  toward 
the  left  and  terminate  in  the  splenic  group  of  nodes  which  are  situ- 
ated near  the  hilum  of  the  spleen,  between  the  folds  of  the  gastro- 
splenic  omentum.  These  may  also  be  followed  along  the  course  of 
the  splenic  vessels,  the  upper  border  of  the  pancreas,  to  their  ter- 
mination in  the  nodes  about  the  cceliac  axis. 


OPERATIONS  UPON  THE  STOMACH. 

Plication  of  Gastro-hepatic  Ligaments,  etc.  (Beyea). — This  op- 
eration consists  practically  in  "reefing"  the  lesser  omentum,  the 
ligaments — gastro-hepatic  and  gastro-phrenic — which  suspend  the 
stomach  from  the  liver  and  diaphragm.  It  is  done  for  the  purpose 
of  raising  the  stomach  up  into  its  normal  position  in  conditions  of 
gastroptosis. 

Incision  is  placed  in  the  middle  line,  three  to  four  inches  long, 
between  the  ensif orm  process  and  umbilicus.  After  the  abdomen  has 
been  opened  the  liver  is  retracted  upward  and  the  stomach  drawn 
downward.  In  this  way  the  gastro-hepatic  ligament  (the  fold  of  peri- 
toneum that  attaches  the  stomach  to  the  liver)  and  the  gastro- 
phrenic ligament  (a  portion  of  the  same  fold  that  attaches  the  car- 
diac end  of  the  stomach  to  the  diaphragm)  are  exposed  to  view  and 
put  upon  the  stretch  and  their  increased  length  can  be  readily  ap- 
preciated. Three  rows  of  interrupted  silk  sutures  are  placed  in  the 
ligaments. 

Those  of  the  first  row  are  placed  about  one  inch  or  less  apart 
and  each  takes  a  bite  of  from  one-half  to  one  inch,  the  bites  being 
made  progressively  smaller  as  the  cardiac  end  of  the  stomach  is 
approached.  The  ends  of  all  the  sutures  of  this  first  row  are  seized 
and  held  with  an  artery  forceps.  The  sutures  of  the  second  row  are 
then  introduced  and  take  bites  beyond  those  of  the  first,  and  those 
of  the  third  row  beyond  those  of  second  (Fig.  95).  Finally  the 
sutures  are  all  tied,  first  those  of  the  first  row,  then  those  of  the 


242 


ABDOMEN  AND  BACK. 


Fig.  94.— Various  Abdominal  Incisions.  B,  Battle  incision;  C,  incision  for 
left  inguinal  colostomy;  F,  Fenger  incision  for  stomach;  G,  Vertical  and 
oblique  incisions  for  gall-bladder,  etc.;  H,  von  Hacker's  incision  for  gastros- 
tomy; M,  McBurney  incision  for  appendicectomy;  S,  incision  for  suprapubic 
cystotomy.  In  middle  line  above  umbilicus  is  linea  alba  incision  for  opera- 
tions upon  stomach.  X  indicates  location  of  anterior  superior  iliac  spine. 
Dotted  line  drawn  from  spine  to  the  umbilicus. 


OPERATIONS  UPON  THE  STOMACH. 


243 


second  row,  and  last  those  of  the  third  row.  The  result  of  this 
operation  is  that  the  stomach,  especially  its  pyloric  portion,  is  raised 
upward  toward  the  liver  and  diaphragm  without  interfering  with  the 
mobility  of  the  organ  which  is  essential  to  its  properly  performing  its 
functions. 

The  sutures  are  of  the  mattress  variety,  and  are  introduced  with 
a  small,  curved,  round-pointed  needle. 


Fig.  95.— Plication  of  Gastro-hepatic  Ligament  (Beyea).  1,  2,  and  3  indi- 
cate a  single  stitch  of  each  of  the  three  rows  that  are  placed  in  the  gastro- 
hepatic  ligament  as  represented  by  the  dotted  lines. 


Gastroplication. — The  folding  in,  or  "reefing,"  of  a  portion  of 
the  wall  of  the  stomach  in  order  to  diminish  the  size  of  the  organ. 
This  operation  was  first  performed  by  Bircher,  and  is  especially  ap- 
plicable to  cases  of  dilatation  without  stenosis  of  the  pyloric  orifice. 

The  abdominal  incision,  five  to  six  inches  in  length,  may  be 
placed  a  finger's  breadth  distant  from  and  parallel  with  the  left  free 


244 


ABDOMEN  AND  BACK. 


border  of  the  ribs,  commencing  above  near  the  tip  of  the  ensiform 
process,  or  it  may  be  located  in  the  linea  alba,  reaching  from  a  point 
one  inch  below  the  tip  of  the  ensiform  process  downward  as  far  as 
the  umbilicus.  Through  either  of  these  incisions  the  stomach  may 
be  brought  out  upon  the  abdominal  wall. 


Fig.  96. — Gastroplication.  Lower  border  o£  the  stomach  is  turned  up  and 
stitched  near  the  lesser  curvature  with  a  single  row  of  sutures  (4),  method 
of  Bircher;    with  four  rows  of  sutures  (1,  2,  3,  4),  method  of  Weir. 


According  to  Bircher,  the  anterior  wall  of  the  stomach  is  folded 
upon  itself  so  that  the  greater  curvature  may  be  brought  up  close 
to  the  lesser  curvature  and  fixed  in  this  position  with  a  row  of  inter- 
rupted silk  sutures ;  these  should  take  a  good,  broad  bite  in  the  wall 
of  the  stomach,  including  its  serous  and  muscular  coats.  Care  should 
be  exercised  that  the  sutures  do  not  penetrate  through  the  entire 
thickness  of  the  wall  of  the  stomach.  Twelve  to  fourteen  sutures  are 
usually  required. 


OPERATIONS  UPON  THE  STOMACH.  245 

According  to  Weir,  the  fixation  may  be  made  with  three  or  four 
separate  tiers  of  sutures,  one  superimposed  upon  the  other.  After 
the  stomach  has  been  brought  out  through  the  abdominal  incision, 
its  anterior  wall,  corresponding  to  the  long  diameter  of  the  organ, 


Fig.  97. — Cross  Section  of  the  Stomach  After  Gastroplication 
according  to  the  Method  of  Bircher. 

is  inverted,  and  the  edges  of  the  furrow  thus  made  in  the  wall  of 
the  stomach  united  with  a  row  of  continuous  or  interrupted  silk 
sutures.  A  second  row  of  sutures  is  then  introduced  parallel  with 
and  about  one  inch  distant  from  the  first.     A  third  and  finally  a 


Fig.  98. — Cross  Section  of  Stomach  After  Gastroplication;  the  Turned-Up 
Portion  Fixed  by  Four  Rows  of  Sutures.     (Weir.) 

fourth  row  may  be  introduced,  the  last  row  joining  the  greater  curva- 
ture to  the  upper  part  of  the  anterior  wall  of  the  stomach  near  the 
lesser  curvature.  In  this  way  six  or  eight  inches  of  the  stomach 
wall  may  be  reefed  in  and  the  organ  materially  reduced  in  size.    No 


246  ABDOMEN  AND  BACK. 

doubt  the  folding  of  the  stomach  wall  is  made  more  secure  when 
several  rows  of  sutures  are  used. 

Infolding  of  the  "Wall  of  the  Stomach  for  Ulcer. — This  plan  was 
suggested  by  Mitchell  and  answers  well,  provided  the  ulcerated  area 
is  limited  and  accessible,  especially  if  the  anterior  wall  is  the  portion 
involved.  The  stomach  is  exposed  through  an  incision  in  the  middle 
line  commencing  near  the  tip  of  the  ensiform  process  and  carried 
downward  toward  the  umbilicus.  The  ulcerated  portion  of  the  stomach 
wall  is  infolded  or  inverted  into  the  lumen  of  the  organ  and  fixed 
thus  with  two  rows  of  non-penetrating,  Lembert  sutures  of  silk. 
If  the  posterior  wall  of  the  stomach  is  the  portion  affected  the  operator 
may  attempt  to  gain  access  to  this  part  of  the  organ  through  an 
opening  which  is  made  in  the  gastro-eolic  ligament,  or,  better,  in  the 
transverse  mesocolon. 

The  beneficial  result  of  the  operation  is  due  to  the  fact  that  the 
diseased  portion  is  placed  at  rest — free  from  peristalsis,  etc. — and 
it  gradually  atrophies. 

It  might  be  advisable  to  perform  a  gastrojejunostomy  in  addi- 
tion because  in  some  of  these  cases  the  pyloric  orifice  will  be  found 
to  be  more  or  less  stenosed.  Even  if  no  stenosis  of  the  pyloric  orifice 
is  present  the  gastrojejunostomy  will  be  beneficial  in  that  it  per- 
mits easy  and  quick  evacuation  of  the  stomach. 

Gastrotomy. — This  operation  consists  in  making  an  incision  into 
the  stomach  for  the  purpose  of  extracting  a  foreign  body  lodged  in 
the  stomach  or  impacted  low  down  in  the  oesophagus;  for  explora- 
tion of  the  interior  of  the  stomach,  ulcer,  hemorrhage,  etc.,  and  to 
treat  strictures  in  the  lower  part  of  the  oesophagus. 

Immediately  preceding  any  operation  upon  the  stomach  the 
organ  should  be  emptied  and  irrigated,  if  the  conditions  permit,  with 
the  stomach  tube.  This  is  best  done  after  the  patient  has  been 
anesthetized.  It  is  desirable  that  the  stomach  be  empty  when  it  is 
opened  during  the  course  of  the  operation. 

The  incision  may  be  made  in  the  middle  line  through  the  linea 
alba,  three  to  five  inches  long,  commencing  above  about  one  inch 
below  the  ensiform  process,  and  extending  downward  toward  the  um- 
bilicus; or  an  incision  may  be  made  just  to  the  left  of  the  linea  alba, 
passing  through  the  inner  margin  of  the  left  rectus  muscle;  or  the 
Fenger  incision,  parallel  with  the  free  border  of  the  left  ribs,  may 
be  employed.  This  last  incision  (Fenger)  is  probably  the  best  if  the 
ultimate  object  is  to  reach  the  oesophagus  (see  Fig.  94). 


OPERATIONS  UPON  THE  STOMACH.  247 

Having  carried  the  incision  down  to  the  parietal  layer  of  the 
peritoneum,  this  is  picked  up  with  two  toothed  forceps  and  a  small 
incision  made  between  them  with  the  knife;  through  this  incision 
the  finger  is  introduced,  and  upon  the  finger,  with  a  blunt-pointed 
scissors,  the  opening  in  the  peritoneum  is  enlarged  so  as  to  corre- 
spond in  length  with  the  incision  in  the  abdominal  wall.  Two  fingers 
are  then  introduced  into  the  abdomen  and  the  stomach  searched  for. 
If  there  is  a  foreign  bod}7  in  the  stomach,  this  may  oftentimes  be  felt 
and  serves  as  a  guide  to  the  stomach.  The  thin  anterior  edge  of  the 
left  lobe  of  the  liver  may  be  always  readily  recognized,  and  this  is  a 
good  guide  to  the  stomach,  as  the  stomach  lies  directly  underneath 
this  organ,  being  partly  covered  by  it;  that  part  of  the  anterior  sur- 
face of  the  stomach  which  is  not  covered  by  the  liver  is  accessible  for 
operation;  it  is  seized  with  two  fingers  and  drawn  out  of  the  ab- 
dominal incision.  If  the  stomach  is  diminished  in  size  there  may  be 
some  difficulty  in  drawing  it  out  through  the  incision  upon  the 
abdomen. 

One  should  not  mistake  the  transverse  colon  for  the  stomach. 
The  transverse  colon  lies  below  and  close  to  the  greater  curvature, 
being  connected  with  the  greater  curvature  by  the  great  omentum 
(gastro-colic  ligament) ;  the  great  omentum  is  suspended  free,  apron- 
like, from  the  transverse  colon,  and  when  this  part  of  the  intestine 
is  drawn  out  upon  the  abdomen  the  great  omentum  is  drawn  out 
with  it;  the  colon  can  be  further  identified  by  its  sacculation,  by 
the  little  fatty  appendices  attached  to  it,  and  by  the  stria?  which  run 
along  its  length.  The  wall  of  the  stomach  is  smooth,  and  the  blood- 
vessels ramifying  upon  its  surface  have  a  characteristic  course,  con- 
verging from  the  periphery  toward  the  center;  the  gastro-epiploica 
dextra  and  sinistra  run  along  the  greater  curvature  from  either  end 
of  the  stomach,  anastomosing  with  each  other. 

The  stomach  may  be  examined  by  inspection  and  palpation  be- 
fore it  is  opened.  The  posterior  wall  of  the  stomach  may  be  palpated 
through  an  opening  torn  in  the  gastro-colic  ligament.  If  the  stomach 
has  not  been  previously  emptied,  stricture  of  the  oesophagus,  etc., 
the  attempt  should  now  be  made  by  the  operator  to  express  the  con- 
tents onward  into  the  duodenum  before  it  is  opened. 

A  portion  of  the  stomach  wall  is  drawn  out  through  the  ab- 
dominal incision  and  after  gauze  pads  have  been  properly  arranged 
to  protect  the  peritoneal  cavity  the  stomach  is  incised.  When  the 
incision   is    made    care   should    be   taken   to   prevent   any   stomach 


248  ABDOMEN  AND  BACK. 

contents  from  entering  or  soiling  the  peritoneal  cavity.  If  there 
is  any  fluid  present  in  the  stomach  when  it  is  opened  this  should  be 
swabbed  out  or  removed  with  a  siphon.  The  stomach  is  best  incised 
in  its  long  diameter  and  the  incision  may  vary  from  one  to  three 
inches.  Bleeding  vessels  may  be  secured  with  artery  forceps.  Venous 
hemorrhage  stops  after  the  artery  forceps  have  been  applied  for  a 
short  time,  but  spurting  arterial  branches  should  be  clamped  and 
tied  with  either  fine  silk  or  fine  catgut. 

After  the  removal  of  the  foreign  body  or  examination  of  the 
interior  of  the  stomach  or  treatment  of  ulcer,  etc.,  the  opening  in 
the  stomach  may  be  closed. 

The  closure  of  the  incision  in  the  stomach  is  best  effected  with  a 
continuous  Lembert  suture  of  fine  silk,  which  is  applied  with  a  fine 
curved  surgeon's  needle.  This  suture  includes  the  serous  and  mus- 
cular coats  and  takes  a  good  bite,  each  loop  being  drawn  fairly  tight. 
This  line  of  suture  may  be  reinforced  by  a  second  similar  row  of 
Lembert  sutures  which  bury  the  first  row.  Before  closing  the  open- 
ing in  the  stomach  wall  its  edges  should  be  wiped  with  a  wet  bichlo- 
ride pad.  After  the  closure  has  been  accomplished  the  parts  should 
be  again  swabbed  with  the  bichloride  pad,  followed  by  salt  solution, 
and  the  stomach  then  returned  into  the  abdomen. 

The  wound  in  the  abdomen  is  closed  first  by  a  continuous  catgut 
stitch  which  approximates  the  edges  of  the  parietal  peritoneum,  and 
then  a  sufficient  number  of  interrupted  silk-worm  sutures — each  in- 
cluding the  skin,  aponeurosis,  and  muscle — are  introduced. 

Foe  Bleeding  Ulcee. — Operation  is  indicated  in  this  condition 
when  medical  treatment,  rest,  etc.,  fail  to  control  it  or  if  the  hem- 
orrhage recurs  and  is  profuse.  Owing  to  the  risk  of  increasing  the 
hemorrhage  the  stomach  should  not  be  washed  out  before  operating. 
Loss  of  body  heat  must  be  prevented  as  much  as  possible  during  the 
operation.  When  the  stomach  is  exposed  it  should  be  emptied  by 
expressing  the  contents  onward  into  the  duodenum.  Before  opening 
the  stomach  its  surface  should  be  carefully  examined  by  inspection 
and  palpation  in  an  effort  to  locate  the  ulcer;  a  puckering  of  the 
surface,  thickening  of  the  wall,  or  difference  in  color  may  indicate 
its  site.  If  unable  to  obtain  a  clue  to  the  location  of  the  ulcer  by 
these  means,  then  the  stomach  must  be  incised  and  its  inner  surface 
systematically  explored,  first  the  anterior  wall  and  then  the  posterior, 
and  finally  the  cardiac  and  pyloric  ends.  This  examination  may  be 
made  with  the  naked  eye,  bringing  different  areas  of  the  stomach 


OPERATIONS  UPON  THE  STOMACH. 


249 


Fig.  99.— Posterior  Wall  of  Stomach  pushed  out  through  Incision  in  Ante- 
rior Wall  by  Fingers  Passed  into  Space  behind  Stomach  through  Opening 
in  Gastro-colic  Ligament.     Clamp  applied  to  bleeding  point. 


250  ABDOMEN  AND  BACK. 

wall  into  the  incision,  one  after  the  other,  or  assisted  by  the  intro- 
duction of  a  speculum  and  the  use  of  a  reflector.  The  posterior  -wail 
of  the  stomach  may  be  brought  into  view  by  introducing  one  or  two 
fingers  through  a  rent  in  the  gastro-colic  ligament  so  as  to  reach  the 
posterior  wall  and  invaginate  it,  pushing  it  forward  into  the  incision 
in  the  anterior  wall.  The  first  part  of  the  duodenum  may  also  be 
invaginated  and  examined  in  the  same  manner.  If  no  ulcer  is  found 
and  the  hemorrhage  is  capillary  in  character  or  comes  from  small 
indiscoverable  ulcers,  then  a  gastrojejunostomy  should  be  done. 

If  an  ulcer  can  be  located  it  should  be  excised  if  possible.  The 
edges  of  the  wound  which  is  left  after  the  ulcer  has  been  excised  are 
brought  together  with  catgut  sutures,  one  or  two  layers  being  used; 
if  the  condition  necessitated  cutting  through  the  entire  thickness  of 
the  stomach  wall,  then  the  edges  of  the  peritoneal,  serous  coat  must 
be  united  separately  with  a  Lembert  suture  of  silk.  Bleeding  points 
are  clamped  and  ligated. 

If  the  ulcer  involves  the  posterior  wall  it  may  be  excised  from 
within,  working  through  an  incision  in  the  anterior  wall,  the  edges 
of  the  wound  being  brought  together  afterward  with  a  continuous 
catgut  suture.  If  the  entire  thickness  of  the  posterior  wall  of  the 
stomach  has  been  cut  through,  necessitating  the  application  of  out- 
side Lembert  sutures,  these  can  be  applied  through  an  opening  torn 
in  the  gastro-colic  ligament,  or,  probably  better,  through  a  rent  made 
in  the  transverse  mesocolon.  Adhesions  between  the  posterior  wall 
of  the  stomach  and  neighboring  organs,  especially  the  pancreas,  may 
add  considerable  difficulty  to  the  proper  execution  of  this  plan  of 
treatment. 

Should  the  ulcer  involve  a  part  of  the  stomach  wall  which  is 
inaccessible  for  excision,  cardiac  end,  or  should  excision  appear  in- 
advisable, then  the  effort  may  be  made  to  control  the  hemorrhage 
with  the  Paquelin  cautery,  or,  if  one  or  more  individual  bleeding 
points  are  discovered,  an  attempt  may  be  made  to  clamp  and  ligate 
them.  Owing  to  the  friability  of  the  tissues,  these  ligatures  are  likely 
to  cut  through  and  thus  increase  the  hemorrhage.  Finally,  if  the 
hemorrhage  cannot  be  controlled  by  any  of  the  measures  mentioned, 
then,  without  further  delay,  a  gastrojejunostomy  should  be  performed. 

If  the  ulcer  involves  the  pylorus,  a  pyloroplasty  according  to 
the  method  of  Finney  may  be  done,  excising  the  diseased  area  at  the 
same  time,  or  a  typical  pylorectomy  may  be  performed  if  time  and 
the  patient's  condition  permit;   or  instead  of  either  of  these  radical 


OPERATIONS  UPON  THE  STOMACH.  251 

measures  and  without  further  regard  as  to  the  exact  source  of  the 
bleeding  or  condition  of  the  pylorus,  a  gastrojejunostomy  may  be 
performed.  Time  is  an  important  consideration  in  operations  for 
the  control  of  hemorrhage,  and  the  patient's  condition  may  preclude 
prolonged  or  complicated  operative  procedures. 

For  Treatment  of  Stricture  of  the  (Esophagus. — An  ab- 
dominal incision  parallel  with  the  left  free  horder  of  ribs,  according 
to  Fenger,  is  the  most  satisfactory.  After  the  stomach  has  been 
incised,  as  described  in  the  preceding  paragraphs,  the  finger  is  in- 
troduced through  the  opening  in  the  stomach  and  into  the  oesoph- 
ageal orifice ;  at  times  it  is  necessary  to  make  a  little  steady  pressure 
with  the  finger  before  this  opening  yields  so  as  to  allow  the  finger 
to  enter.  Conical  rubber  bougies  of  increasing  caliber  are  then 
introduced,  one  after  another,  into  the  oesophagus  and  up  beyond 
the  site  of  the  stricture.  If  the  stricture  is  dense  and  unyielding, 
the  operator  may,  according  to  the  method  of  Abbe,  pass  a  thin 
bougie,  carrying  a  strand  of  braided  silk,  up  into  the  oesophagus, 
through  and  beyond  the  stricture,  so  that  the  end  carrying  the  silk 
cord  may  be  felt  in  the  pharynx.  The  silk  cord  is  seized  either  in 
the  back  of  the  pharynx,  through  the  mouth,  or  else  through  an 
incision  which  is  made  for  that  purpose  in  the  side  of  the  neck  and 
upper  part  of  the  oesophagus:  the  bougie  is  then  withdrawn,  leav- 
ing the  silk  thread  behind  it  in  the  oesophagus.  A  conical  bougie 
is  now  again  introduced  into  the  oesophagus  from  below  through  the 
opening  in  the  stomach;  this  bougie  should  be  large  enough  to  be- 
come tightly  engaged  in  the  stricture;  the  ends  of  the  silk  string 
are  then  seized  and  it  is  drawn  back  and  forth  several  times;  it 
will  then  be  observed  that  the  bougie  can  be  passed  farther  and 
farther  into  the  stricture;  bougies  of  increasing  caliber  are  used  in 
this  manner  until  the  stricture  is  sufficiently  relieved.  The  incision 
of  the  stricture  which  is  made  by  the  friction  of  the  silk  string  is 
accomplished  with  but  little  hemorrhage.  The  bougie  and  string 
are  finally  withdrawn  and  a  rubber  tube  which  is  permitted  to  remain 
is  passed  into  the  oesophagus,  its  end  projecting  through  the  opening 
in  the  stomach  and  out  of  the  abdominal  incision.  Besides  this  tube 
which  reaches  up  into  the  oesophagus,  a  second  one  may  be  introduced 
into  the  stomach  and  left  there  for  the  purpose  of  feeding. 

In  the  abdominal  incision  the  edges  of  the  parietal  peritoneum 
are  fixed  to  the  corresponding  margins  of  the  skin  with  several  cat- 
gut sutures  and  the  edges  of  the  opening  in  the  stomach  then  united 


252  ABDOMEN  AND  BACK. 

to  the  edges  of  the  abdominal  incision  with  a  sufficient  number  of 
interrupted  silk  sutures,  the  ends  of  the  sutures  being  left  long  in 
order  to  facilitate  their  removal  later.  The  abdominal  incision, 
except  for  that  portion  to  which  the  stomach  has  been  sutured, 
should  be  closed  with  interrupted  silk-worm  gut  sutures. 


Fig.  100. — Pyloroplasty.    Horizontal  incision  into  the  pylorus. 

This  is  practically  a  gastrostomy,  and  through  the  opening  in 
the  stomach  the  effort  to  relieve  the  stricture  of  the  oesophagus  may 
be  repeated  if  necessary  after  an  interval  of  several  days.  The  gastric 
fistula  that  remains  closes  spontaneously  or  may  be  closed  by  a  sec- 
ondary plastic  operation. 


Fig.  101. — Pyloroplasty.    Horizontal  converted  into  a  vertical  incision 
and  sutures  placed. 

Pyloroplasty. — For  the  relief  of  cicatricial  stricture  of  the  py- 
lorus causing  obstruction  to  the  emptying  of  the  stomach. 

Heinecke-Mikulicz  Method. — The  results  obtained  from  this 
operation  are  not  entirely  satisfactory.  In  many  cases  the  symptoms 
of  pyloric  obstruction  return  after  a  brief  period  of  relief.  The 
operation  should  not  be  performed  in  cases  where  a  condition  of 


OPERATIONS  UPON  THE  STOMACH.  253 

active  ulceration  exists.  Under  such  conditions  a  pylorectomy  is  the 
preferable  operation. 

The  stomach  is  exposed  through  an  incision  in  the  middle  line 
and  its  pyloric  end  drawn  out  through  the  incision.  Pads  are  then 
properly  placed  to  protect  the  peritoneal  cavity  during  the  rest  of 
the  operation. 

The  pylorus  is  incised  in  its  long  axis,  a  clean  cut  being  made 
through  all  its  coats;  this  incision  should  be  liberal,  from  4  to  6  cm. 
long,  reaching  crosswise  from  the  stomach  through  the  pylorus  into  the 
duodenum.  The  edges  of  the  incision  are  drawn  widely  apart  by 
tenacula  hooked  in  the  middle  of  each  edge,  and  in  this  way  the 
transverse  incision  becomes  converted  into  a  vertical  one.  In  this 
position,  after  sponging  its  margins  with  a  bichloride  pad,  the  open- 
ing is  closed  by  a  row  of  interrupted  Lembert  sutures  which  take  a 
good,  deep,  and  broad  bite,  these  being  reinforced  and  buried  by  a 
second  row  of  Lembert  sutures,  which  may  be  continuous.  All  the 
sutures  are  of  silk.  Care  should  be  taken  to  close  the  opening  ac- 
curately, especially  in  the  middle  of  each  edge, — the  points  which 
correspond  to  the  extremities  of  the  original  incision.  The  result  is 
a  marked  widening  of  the  pyloric  orifice.  The  wound  in  the  abdo- 
men is  closed  in  the  usual  way. 

Finney  Method. — The  result  of  this  operation  is  a  gastro- 
duodenostomy.  For  benign  stricture  of  the  pylorus,  for  chronic 
ulcer,  e.tc. 

The  incision,  longitudinal,  is  placed  to  the  right  of  the  median 
line,  penetrating  between  the  fibers  of  the  rectus.  It  commences 
near  the  ensiform  cartilage  and  is  carried  downward  for  a  distance 
of  from  six  to  eight  inches. 

After  the  abdomen  has  been  opened  the  pylorus  is  sought  for 
and  adhesions  that  bind  it  to  the  adjacent  organs  divided.  The 
pyloric  end  of  the  stomach  and  the  first  part  of  the  duodenum  should 
be  freed  as  completely  as  possible.  Upon  the  thoroughness  with 
which  this  step  of  the  operation  is  accomplished  will  depend  in  a 
large  measure  the  success  of  the  operation  and  the  facility  and  rapid- 
ity with  which  the  subsequent  steps  are  executed.  At  times  the 
pylorus  will  be  found  to  be  apparently  hopelessly  adherent,  but  after 
a  little  patient  effort  with  blunt  dissection  and  occasional  careful, 
judicious  use  of  the  scalpel  it  may  be  freed  with  comparative  ease. 

After  the  pylorus,  etc.,  have  been  mobilized  a  silk  suture  which 
is  to  serve  as  a  tractor  is  placed  in  the  upper  part  of  the  pylorus, 


254  ABDOMEN  AND  BACK. 

and  with  this  the  pylorus  is  drawn  upward.  A  second  tractor  suture 
is  then  inserted  in  the  anterior  wall  of  the  stomach,  near  the  greater 
curvature  and  a  third  in  the  anterior  wall  of  the  duodenum.  The 
second  and  third  tractors  should  be  placed  at  points  equidistant 
— about  12  cm. — from  the  tractor  that  has  been  applied  to  the 
pylorus.  These  sutures  are  temporary  and  should  be  of  silk  and 
take  a  good,  broad  bite  in  the  walls  of  the  organs,  but  should  not 
penetrate  through  their  entire  thickness.  The  second  and  third 
serve  to  indicate  the  lower  ends  of  the  incisions  that  are  to  be  made 
in  the  stomach  and  duodenum  respectively  and  should  be  placed  as 
low  as  possible  in  order  that  the  new  pyloric  opening  may  be  suffi- 
ciently large.  While  the  upper,  pyloric,  tractor  is  drawn  upward,  the 
lower,  gastric  and  duodenal,  tractors  are  pulled  downward  so  as  to 
make  the  stomach  and  duodenal  surfaces  taut  and  bring  them  into 
apposition  in  order  to  facilitate  the  placing  of  the  line  of  suture 
that  is  to  join  them  together.  The  first  part  of  the  duodenum  and 
the  corresponding  part  of  the  stomach,  along  its  greater  curvature, 
are  united  from  above  downward  as  far  as  the  lower,  gastric  and 
duodenal,  tractors  with  a  continuous  non-penetrating  Lembert  suture 
of  silk.  After  this  row  of  sutures  has  been  applied,  a  second  row  of 
sutures,  mattress  variety,  is  introduced  along  a  line  anterior  to  the 
first  row  of  sutures.  Ample  space  should  be  left  between  the  first, 
posterior,  row  of  sutures  and  this  second,  anterior,  row  of  mattress 
sutures  in  order  to  permit  of  making  the  incisions  in  the  stomach 
and  duodenum  between  them.  The  anterior  mattress  sutures  should 
take  a  good  bite  in  the  serous  and  muscular  coats  of  the  stomach 
and  duodenum,  but  they  should  not  penetrate  the  entire  thickness  of 
the  walls  of  the  organs. 

The  anterior  row  of  mattress  sutures  are  not  tied,  but  are  left 
long  and  loose,  their  ends  caught  with  artery  forceps  and  their 
loops  drawn  upward  and  downward  with  blunt  hooks.  While  the 
mattress  sutures  are  thus  held  out  of  the  way,  the  incision  into  the 
stomach  and  duodenum  is  made.  The  incision  is  horseshoe-shaped. 
The  gastric  arm  of  the  incision  is  made  in  the  stomach  wall  com- 
mencing just  above  the  lowest  point  of  the  line  of  suture ;  it  is  car- 
ried up  to  and  through  the  pylorus  and  around  into  the  attached 
portion  of  the  duodenum  to  a  point  opposite  where  it  commenced  in 
the  stomach.  Hemorrhage  from  the  edges  of  the  incisions  in  the 
stomach  and  duodenum  is  then  controlled;  for  this  purpose  clamps 
may  be  applied  temporarily;  but,  as  a  rule,  it  is  unnecessary  to  em- 


Pig.   102. — Pyloroplasty   (Finney).     Tractor  stitches  have  been  placed  and 
the  posterior  line  of  suture  joining  duodenum  to  stomach  has  been  inserted. 


Fig.    103. — Pyloroplasty   (Finney).     The  anterior  row   of   mattress   sutures 
has  been  introduced,   but  not  tied. 


Fig.  104. — Pyloroplasty  (Finney).  Anterior  mattress  sutures  retracted 
upward  and  downward  and  horseshoe-shaped  incision  made  one  arm  cutting 
into  duodenum  and  the  other  into  stomach. 


Fig.  105. — Pyloroplasty  (Finney).  Posterior  raw  edges  of  incisions  in 
duodenum  and  stomach  have  been  united  with  a  continuous  suture.  It  re- 
mains now,  to  complete  the  operation,  to  release  the  anterior  mattress 
sutures,   draw  them  tight,   and  tie. 


OPERATIONS  UPON  THE  STOMACH.  .  255 

ploy  any  ligatures  because  the  bleeding  usually  ceases  when  the  edges 
of  the  incisions  are  sutured  together.  It  is  desirable  to  resect  as 
much  as  possible  of  the  cicatricial  tissue  present  upon  either  side  of 
the  incision  in  order  to  limit  subsequent  contraction.  The  redundant 
edges  of  the  mucous  membrane  may  be  trimmed  away  so  as  to  make 
the  opening  of  the  new  pylorus  as  large  and  free  as  possible. 

The  contiguous  edges  of  the  horseshoe  opening  for  the  posterior 
part  of  their  extent  are  united  to  each  other  with  a  continuous, 
through-and-through  suture  of  catgut.  The  anterior  row  of  mat- 
tress sutures  are  then  drawn  tight  and  tied  and  the  operation  is 
thus  complete.  Several  additional  Lembert  sutures  of  silk  may  be 
placed  in  front  of  the  line  of  mattress  sutures,  burying  them,  so  as 
to  secure  the  parts  still  more  firmly;  this  is,  however,  probably  un- 
necessary. 

The  incision  in  the  abdomen  is  closed  either  layer  by  layer  or 
else  with  a  sufficient  number  of  interrupted  sutures  of  silk  that 
penetrate  all  the  layers  of  the  abdomen,  special  care  being  taken  to 
include  the  peritoneum  in  each  stitch. 

Gastrostomy. — The  formation  of  a  permanent  gastric  fistula  for 
the  purpose  of  feeding  in  cases  of  simple  or  malignant  stricture  of 
the  oesophagus.  The  fistula  should  permit  the  introduction  of  nutri- 
ment and  at  the  same  time  prevent  the  escape  of  stomach  contents. 

Vo^  Hacker's  Method. — The  operation  may  be  done,  if  nec- 
essary, under  cocain  anaesthesia.  This  method  is  used  only  in  ad- 
vanced cases,  where  time  presses. 

The  incision,  three  inches  long,  is  made  through  the  left  rectus 
muscle;  it  should  be  placed  about  one  and  one-fourth  inches  to  the 
left  of  the  middle  line,  commencing  above,  about  one  inch  below 
the  free  border  of  the  ribs.  After  passing  through  the  integument 
the  anterior  layer  of  the  sheath  of  the  rectus  is  reached  and  incised, 
and  then,  separating  between  the  fibers  of  this  muscle  bluntly  with 
the  handle  of  the  knife,  the  posterior  layer  of  the  sheath  of  the 
rectus  is  exposed;  after  this  layer  has  been  incised  the  parietal  peri- 
toneum is  exposed;  this  is  picked  up  with  two  toothed  forceps  and 
between  these  a  small  incision  is  made  with  the  knife.  Through  this 
small  opening  the  finger  is  introduced  into  the  abdomen  and  the 
incision  further  enlarged  with  blunt-pointed  scissors.  Now,  corre- 
sponding to  the  middle  of  the  abdominal  incision,  upon  each  side,  the 
parietal  peritoneum  is  fixed  to  the  edge  of  the  muscle  with  a  single 
catgut  suture.     Two  fingers  are  then  introduced  into  the  abdomen 


256  ABDOMEN  AND  BACK. 

and  the  anterior  wall  of  the  stomach  is  seized  and  drawn  out  of  the 
wound.  Two  silk  sling  sutures  are  then  introduced  into  the  wall  of 
the  stomach;  these  should  take  a  good,  broad  bite  in  the  wall  of  the 
stomach,  but  should  not  penetrate  into  its  cavity,  and  should  be 
placed  about  one  and  one-half  inches  apart  and  one  above  the  other; 
they  are  simply  to  serve  as  tractors  to  steady  the  stomach  in  the 
wound,  and  should  not  be  withdrawn  until  after  the  stomach  has 
been  opened.  They  are  useful  guides  when  the  time  comes  later  to 
incise  the  stomach. 

Now,  with  a  fairly  large  curved  surgeon's  needle  a  silk  suture 
is  passed  through  the  edges  of  the  upper  part  of  the  abdominal  in- 
cision; this  should  include  the  whole  thickness  of  the  abdominal 
wall,  care  being  taken  not  to  omit  the  parietal  peritoneum.  This 
suture  is  not  tied.  A  similar  stitch  is  then  passed  through  the  lower 
end  of  the  wound,  and  this  is  also  left  untied.  Just  below  the  upper 
suture,  the  first  one  introduced,  another  similar  suture  is  passed, 
but  this  includes,  in  addition,  the  wall  of  the  stomach:  it  should 
take  a  good,  broad  bite  in  the  wall  of  the  stomach,  but  without 
entering  its  cavity;  this  suture  is  placed  just  above  the  upper  of  the 
two  sling  tractor  stitches;  again,  in  the  lower  part  of  the  wound,  a 
stitch  is  taken  similar  to  the  preceding  and  which  likewise  includes 
the  wall  of  the  stomach;  this  is  placed  just  below  the  lower  sling 
stitch.  These  four  sutures  are  tied  and  cut  short,  and  the  wound 
is  thus  partly  closed  above  and  below,  and  the  stomach  fixed  at  the 
same  time  to  the  edges  of  the  incision  by  two  good,  firm  sutures. 
The  wall  of  the  stomach  is  then  further  fixed  to  the  edges  of  the 
incision  by  three  or  four  additional  non-penetrating  stitches  on  each 
side;   these  may  be  of  fine  chromicized  catgut  or  of  fine  silk. 

The  wound  is  packed  and  dressed,  and  after  the  lapse  of  one  or 
two  days  the  stomach  is  opened  between  the  two  sling  sutures  which 
were  left  in  situ.  It  is  better  to  make  this  opening  in  the  stomach 
with  a  sharp  knife,  rather  than  with  a  Paquelin  which  causes  a  sloughy 
wound  and  which,  when  it  cicatrizes,  may  be  larger  than  desired. 
The  opening  in  the  stomach  should  be  one-half  inch  long,  just  large 
enough  to  admit  a  tight-fitting  tube.  The  sling  sutures  are  not  with- 
drawn until  after  the  opening  has  been  made  in  the  stomach.  If  it  is 
intended  to  open  the  stomach  immediately,  which  ought  to  be  avoided 
if  possible,  the  union  of  the  stomach  to  the  edges  of  the  abdominal 
incision  must  be  made  more  accurate  in  order  to  prevent  possible 
leakage  and  peritoneal  infection. 


OPERATIONS  UPON  THE  STOMACH. 


257 


Method  of  Ssabanajew  and  Fkanck. — A  very  satisfactory 
operation.  The  incision  (Fenger)  should  be  placed  parallel  with  the 
left  free  border  of  the  ribs  and  should  be  not  more  than  two  inches 
long,  commencing  above  to  the  side  of  the  ensiform  process.  The 
middle  of  the  incision  should  be  opposite  the  tip  of  the  cartilage  of 
the  eighth  rib.  The  incision  is  continued  down  through  the  muscles 
and  parietal  peritoneum.    The  margins  of  the  peritoneum  are  fixed  to 


i  A 


Fig.    106.  —  Gastrostomy  (Ssabanajew-  Fig.   107.  —  Gastrostomy   (Ssabanajew- 

Franck).      Cone-shaped    process    of    the  Franck).     Apex  of  cone-shaped   process 

anterior  wall  of  the  stomach  (S)  drawn  (AS)    sutured    to    the    edges    of    second 

out  through  abdominal  incision  with  a  incision  over  the  ribs, 

silk  tractor  passed  through  its  apex, 
its  base  sutured  all  around  to  the  edges 
of  the  parietal  peritoneum  and  trans- 
versalis  fascia,  etc. 

the  edges  of  the  muscles  in  the  abdominal  incision  with  one  or  two 
silk  or  catgut  stitches  on  either  side,  near  the  middle.  The  anterior 
wall  of  the  stomach,  near  the  fundus,  is  then  seized  with  two  fingers, 
and  drawn  out  of  the  wound  in  a  cone-shaped  process  one  and  one- 
half  to  two  inches  long  and  a  silk  sling  suture  passed  through  its  apex 
to  serve  as  a  tractor.  The  base  of  this  process  of  the  stomach  wall  is 
fixed  all  around  to  the  edges  of  the  incision  in  the  abdomen  with  a 
continuous  silk  stitch.     This  stitch  should  include  the  serous  and 


258  ABDOMEN  AND  BACK. 

muscular  coats  of  the  stomach  and  the  edges  of  the  parietal  peri- 
toneum and  transversalis  fascia  and  deep  muscular  layer  in  the  ab- 
dominal incision.  They  do  not  pass  through  the  skin  nor  should 
they  pass  through  the  entire  thickness  of  the  stomach  wall.  After 
this  step  of  the  operation  has  been  completed  a  second  short  incision 
about  three-fourths  inch  long  is  made  through  the  integument,  one  and 
one-half  inches  above  and  parallel  with  the  first  incision  and  well  above 
the  free  border  of  the  ribs.  The  bridge  of  integument  that  intervenes 
between  this  and  the  first  incision  is  then  raised  bluntly  with  the 
handle  of  the  knife,  and,  with  the  silk  sling  as  a  tractor,  the  apex  of 
the  cone-shaped  process  of  the  stomach  wall  is  drawn  through  into 
the  second  small  incision,  where  it  is  fixed  with  about  four  interrupted 
silk  sutures.  The  edges  of  the  skin  corresponding  to  the  first  in- 
cision are  finally  approximated  with  several  interrupted  silk-worm 
gut  sutures,  the  conical  process  of  the  stomach  wall  being  thus  buried 
underneath  the  bridge  of  tissue  between  the  two  incisions.  After 
the  apex  of  the  cone-shaped  process  of  the  stomach  has  been  sutured 
to  the  second  small  incision,  it  may  be  opened  and  a  tube  introduced 
for  the  purpose  of  feeding.  A  fistulous  tract  about  two  inches  long 
which  is  bent  around  the  free  border  of  the  ribs  and  leads  into  the 
stomach  is  the  result. 

Robson  Modification. — The  incision  is  vertical,  one  and  one-half 
inches  long  and  placed  over  the  outer  third  of  the  left  rectus  muscle 
commencing  three-quarters  inch  below  the  costal  margin.  Pene- 
trating bluntly,  the  fibers  of  the  rectus  are  separated,  not  cut,  and 
the  posterior  layer  of  the  sheath  of  the  rectus  exposed.  This  layer, 
together  with  the  parietal  peritoneum,  is  divided,  making  an  open- 
ing about  one  inch  long.  A  process  of  the  anterior  wall  of  the 
stomach,  toward  its  cardiac  end,  is  seized  and  drawn  out  through  the 
incision  for  a  distance  of  one  and  one-half  inches.  The  base  of  the 
process  of  stomach  is  fixed  to  the  edges  of  the  parietal  peritoneum 
and  transversalis  fascia  with  four  to  six  sutures.  These  sutures  are 
of  silk  and  interrupted,  and  as  they  catch  the  wall  of  the  stomach 
they  penetrate  through  the  serous  and  muscular  coats  only,  joining 
the  stomach  to  the  edge  of  the  peritoneum  and  transversalis  fascia. 
A  transverse  incision  is  then  made  through  the  skin  and  fat  about 
one  inch  above  the  upper  end  of  the  first  incision  cutting  down  upon 
the  cartilage  of  the  ribs.  The  bridge  of  skin  and  fat  between  the  two 
incisions  is  undermined  and  the  apex  of  the  stomach  process  drawn 
through  and  secured  in  the  second  incision  by  transfixing  it  with  two 


OPERATIONS  UPON  THE  STOMACH.  259 

harelip  pins.  -The  edges  of  the  first  incision  are  closed  over  the  process 
of  stomach  with  several  sutures  of  silk-worm  gut.  The  stomach  can 
be  opened  at  once  or  left  for  six  hours  so  as  to  allow  time  for  adhe- 
sions to  form. 

Witzel's  Method  is  a  most  satisfactory  operation.  An  incision 
(Fenger)  about  two  inches  long  is  made  through  the  integument, 
aponeurosis,  and  muscle  down  to  the  parietal  peritoneum,  which  layer 
is  then  picked  up  with  toothed  forceps  and  incised. 

Instead  of  cutting  through  the  muscles  of  the  abdominal  wall 
one  may,  after  the  aponeurotic  layer  (sheath  of  the  rectus)  has  been 
exposed  and  divided,  separate  bluntly  between  the  fleshy  fibers  of 
the  several  muscles,  between  those  of  the  rectus  in  a  vertical  direc- 
tion and  those  of  the  transversalis  in  a  transverse  direction;  the 
muscles,  having  been  thus  separated,  are  drawn  apart  with  broad 
retractors,  and  the  peritoneum  incised  for  a  length  corresponding  to 
the  length  of  the  incision  in  the  integument.    . 

It  is  probably  just  as  well  as  in  most  cases  to  cut  the  muscles,  as 
the  separation  between  the  fibers  adds  to  the  difficulty  of  the  opera- 
tion and  consumes  time,  all  to  little  or  no  purpose. 

Instead  of  the  Fenger  incision  as  described  above  one  may  make 
a  vertical  incision  (Mikulicz),  4  to  5  cm.  long,  just  to  the  left  of  the 
middle  line,  passing  through  the  inner  edge  of  the  rectus  muscle  and 
located  midway  between  the  ensif  orm  process  and  the  umbilicus. 

Whichever  incision  is  employed,  after  the  abdomen  has  been 
opened  the  parietal  peritoneum  is  fixed  to  the  edges  of  the  incision 
with  one  or  two  catgut  stitches  on  each  side  to  prevent  its  retrac- 
tion. These  stitches  fix  the  parietal  peritoneum  to  the  transversalis 
fascia  and  the  deeper  layer  of  muscle,  but  do  not  include  the  skin. 

Two  fingers  are  then  introduced  into  the  abdomen,  and  the  ante- 
rior wall  of  the  stomach  seized  and  drawn  out  of  the  wound  and 
surrounded  with  aseptic  gauze  pads,  so  that  the  succeeding  steps  of 
the  operation  may  be  done  extraperitoneally. 

A  No.  25  F.  soft  rubber  catheter  is  placed  upon  the  surface  of 
the  stomach  so  that  it  is  directed  obliquely  downward  and  toward 
the  left,  and  in  this  position  it  is  fixed  with  four  interrupted  silk 
sutures,  which  pick  up  the  wall  of  the  stomach  on  either  side  of  the 
catheter,  each  taking  a  good,  broad  bite,  but  not  penetrating  through 
the  entire  thickness  of  the  wall  of  the  stomach.  In  this  way  the 
stomach  wall  is  raised  in  a  fold,  or  plait,  upon  each  side  of  the  tube ; 
so  that  when  the  sutures  are  tied  these  two  folds  meet  and  completely 


260 


ABDOMEN  AND  BACK. 


bury  the  tube.  Corresponding  to  the  end  of  the  catheter  a  very  small 
opening  is  now  made  in  the  stomach  wall  with  the  point  of  the  knife, 
and  through  this  the  end  of  the  catheter  is  pushed  so  that  about  three 
inches  of  its  length  is  within  the  stomach.  The  opening  in  the  stom- 
ach should  be  so  small  that  the  tube  will  be  a  tight  fit.  The  free  end 
of  the  tube  is  closed  with  a  ligature  or  forceps  to  prevent  the  escape 
of  stomach  contents.  The  four  sutures  which  have  been  introduced 
across  the  tube  into  the  stomach  wall  are  now  tied,  and  thus  the  tube 
is  imbedded  between  the  two  folds,  which  form  a  canal  about  one  and 
one-half  inches  long  containing  the  tube.     A  sufficient  number  of 


Fig.  108.— Gastrostomy  (Witzel).  The 
end  of  the  tube  is  passed  through  a 
small  incision  into  the  stomach,  the 
wall  of  the  stomach  being  raised  up 
upon  each  side  of  the  tube  and  sutures 
introduced. 


Fig.  109.— Gastrostomy  (Witzel).  The 
sutures  have  been  tied  and  the  folds  of  the 
Btomnch  wall  united  over  the  tube  thus 
burying  it. 


additional  silk  sutures  should  be  introduced  to  secure  the  accurate 
coaptation  of  the  two  folds  of  the  stomach  wall  over  the  tube,  and 
at  the  point  where  the  end  of  the  tube  enters  the  stomach  the  sutures 
should  be  extended  a  sufficient  distance  beyond  to  insure  against 
leakage  from  the  stomach  around  the  tube.  That  part  of  the  stom- 
ach wall  underneath  which  the  tube  is  buried  and  that  immediately 
adjacent  to  the  catheter  as  it  emerges  from  the  canal  formed  by  the 
plaiting  of  the  wall  of  the  stomach  should  now  be  joined  with  inter- 
rupted silk  sutures  to  the  edges  of  the  parietal  peritoneum  and  trans- 
versalis  fascia  upon  either  side  of  the  abdominal  incision;  these 
sutures  should  take  a  good,  broad  bite  in  the  wall  of  the  stomach, 


OPERATIONS  UPON  THE  STOMACH.  261 

but  should  not  pass  through  its  entire  thickness;  they  serve  to  fix 
that  part  of  the  wall  of  the  stomach  which  is  immediately  adjacent  to 
the  tube,  to  the  parietal  peritoneum. 

The  abdominal  incision  is  closed,  except  for  a  small  portion 
above,  just  sufficient  to  allow  the  catheter  to  emerge,  with  several 
interrupted  silk-worm  gut  sutures,  each  passing  through  all  the 
layers  of  the  abdomen,  including  the  parietal  peritoneum. 

Kadee  Method. — An  excellent  procedure.  The  incision  is  made 
about  one  inch  below  and  parallel  with  the  left  free  border  of  the 
ribs,  about  three  inches  long,  the  middle  of  the  incision  opposite 
the  tip  of  the  eighth  costal  cartilage.  Instead  of  cutting  the  mus- 
cular layers,  the  operator  may  penetrate  bluntly,  separating  between 
their  fibers,  passing  through  the  rectus  vertically  and  the  trans- 
versalis  transversely.  The  transversalis  fascia  and  parietal  perito- 
neum are  incised  in  an  oblique  direction,  along  the  same  line  as  the 
integument.  Some  operators  prefer  the  vertical  incision.  This  is 
made  over  the  middle  of  the  left  rectus,  commencing  above  about  one 
inch  below  the  free  border  of  the  costal  cartilage  and  is  carried  down- 
ward for  about  three  inches.  Whichever  incision  is  employed,  after 
the  abdomen  has  been  opened  the  edges  of  the  parietal  peritoneum 
are  fixed  to  the  edges  of  the  transversalis  fascia  upon  either  side  of 
the  abdominal  incision  with  several  catgut  sutures. 

A  portion  of  the  anterior  wall  of  the  stomach  is  seized  with  the 
fingers  and  brought  up  into  the  abdominal  incision.  Pads  are  placed 
to  protect  the  parts  and  a  very  small  opening  is  made  in  this  part  of 
the  stomach  with  the  knife.  A  soft-rubber  catheter  about  as  big 
around  as  a  lead-pencil  is  introduced  through  this  incision,  into  the 
stomach  for  about  two  inches  and  fixed  to  the  edge  of  the  incision 
with  a  single  catgut  suture. 

Four  sutures  are  then  introduced  in  the  wall  of  the  stomach, 
two  above  the  catheter  and  two  below.  These  sutures  are  of  silk, 
of  the  non-penetrating,  Lembert  variety.  They  are  placed  about 
one-third  of  an  inch  apart  and  should  take  a  good  broad  bite  pene- 
trating through  the  serous  and  muscular  coats.  There'  should  be 
included  between  the  sutures  a  space  about  three-fourths  inch  broad. 
When  these  sutures  are  tied  they  serve  to  raise  the  wall  of  the  stom- 
ach up  around  the  catheter  in  the  shape  of  two  longitudinal  folds 
which  have  the  effect  of  infolding  the  catheter  into  the  lumen  of  the 
stomach  for  a  depth  of  about  one-half  inch.  A  second  tier  of  four 
sutures  is  introduced  in  a  similar  manner,  picking  up  the  wall  of  the 


262  ABDOMEN  AND  BACK. 

stomach  about  one-half  inch  beyond  the  first  row  upon  each  side, 
burying  these  and  at  the  same  time  still  further  infolding  the  cathe- 
ter into  the  cavity  of  the  stomach.  A  third  tier  of  sutures  may  be 
used,  but  these  are  probably  unnecessary.  The  ends  of  the  upper- 
most and  lowermost  sutures  are  left  long  to  serve  as  tractors  to 
steady  the  stomach  during  the  next  step  of  the  operation  (see  Fig. 
112). 

The  stomach,  the  portion  immediately  adjacent  to  the  catheter 
as  it  emerges  from  the  canal  formed  by  the  infolded  portion  of  the 
wall  of  the  stomach,  is  fixed  to  the  edges  of  the  parietal  perito- 
neum and  transversalis  fascia  in  the  abdominal  incision  with  sev- 
eral interrupted  sutures, — two  or  three  on  either  side  and  one  above 
and  one  below.  These  sutures  are  of  silk  and  do  not  penetrate  the 
entire  thickness  of  the  wall  of  the  stomach,  but  the  serous  and  mus- 
cular coats  only. 

The  abdominal  incision  is  closed,  except  for  the  small  space 
through  which  the  catheter  emerges,  with  several  penetrating  sutures 
of  silk-worm  gut. 

Nutrient  fluids  may  be  introduced  through  the  catheter  into  the 
stomach  immediately  if  the  condition  of  the  patient  demands  it. 

Gastrorrhaphy. — Suture  of  the  wall  of  the  stomach  for  perfora- 
tion due  to  ulcer  or  stab  or  gunshot  wounds.  The  surgeon  should 
remember  in  connection  with  stab  and  gunshot  wounds  that  the 
pancreas  from  its  position  is  especially  liable  to  be  injured  also. 

Ulcer  more  commonly  affects  the  posterior  wall  of  the  stomach 
than  the  anterior  wall.  Perforation  due  to  ulcer,  however,  is  more 
frequently  met  with  on  the  anterior  wall.  There  may  be  more  than 
one  perforation.  The  stomach  should  not  be  washed  out  before 
operating  if  perforation  is  suspected.  An  incision  is  made  in  the 
middle  line  through  the  linea  alba  from  a  point  just  below  the  ensi- 
form  process  to  the  umbilicus  and  the  stomach  exposed. 

The  entire  stomach  should  be  carefully  explored,  first  the  ante- 
rior wall  and  then  the  posterior.  In  order  to  explore  the  posterior 
wall  an  opening  may  be  torn,  not  cut,  in  the  gastro-colic  ligament  or 
preferably  in  some  cases  in  the  transverse  meso-colon.  Through  the 
opening  thus  made  access  may  be  had  to  the  posterior  wall  of  the 
stomach. 

If  the  wound  in  the  stomach  is  small,  it  may  be  closed  with  a 
non-penetrating  purse-string  suture  or  with  a  single  row  of  Lembert 
sutures  of  silk.    These  sutures  should  take  a  good,  broad  bite  in  the 


\. 

^t~~3* 

Y 

m'""' 

1 

■    «■•■ 

I   S* 

J^m 

■ 

Fig.  110. — Gastrostomy  (Kader).  Tube  intro- 
duced through  hole  in  stomach.  The  wall  of 
stomach  is  raised  in  two  folds  by  four  sutures 
that  have   been   inserted. 


Fig.  111.— Gastrostomy  (Kader).  Four  sutures 
shown  in  Fig.  110  have  been  tied  and  two  more 
folds  raised  with  four  additional  sutures. 


Fig.  112. — Gastrostomy  (Eader).     The  four  sutures  of  the  second  row  have 
been  tied.     One  suture  at  each  end  is  left  long  to  serve  as  tractor. 


OPERATIONS  UPON  THE  STOMACH.  263 

wall  of  the  stomach,  and  should  include  the  serous  and  muscular 
coats  only;  they  should  not  pierce  the  entire  thickness  of  the  wall 
of  the  stomach  or  enter  the  mucous  membrane  layer.  It  is  well  to 
reinforce  the  first  row  of  Lembert  sutures  with  a  second  row.  If 
the  wound  in  the  stomach  is  large,  for  example,  after  excision  of 
a  portion  of  the  wall  of  the  stomach  for  ulcer,  etc.,  the  opening  may 
be  closed  with  a  continuous,  through-and-through  suture  of  catgut 
and  then  in  addition  to  this  a  row  of  continuous  Lembert  sutures 
of  silk  are  applied.  These  bury  the  through-and-through  catgut 
stitch  and  bring  the  serous  edges  into  accurate  apposition. 

Before  applying  the  sutures  the  surface  of  the  stomach  imme- 
diately adjacent  to  the  wound  should  be  swabbed  with  a  wet  bichlo- 
ride pad.  If  there  is  difficulty  in  closing  the  perforation  by  suture, 
owing  to  dense  adhesions,  etc.,  it  might  be  plugged  up  by  applying 
a  piece  of  omentum  or  a  coil  of  intestine  and  fixing  it  by  suture  to 
the  stomach. 

If  the  peritoneum  has  become  soiled  by  escaping  stomach  con- 
tents, it  is  well  to  thoroughly  flush  out  the  abdominal  cavity  with 
salt  solution  after  the  opening  in  the  stomach  has  been  closed. 

Gastroplasty. — The  steps  of  this  operation  are  quite  analogous  to 
those  described  in  the  pyloroplasty  of  Heinecke  and  Mikulicz.  For 
hour-glass  contraction  of  the  stomach  due  to  cicatrization,  etc.,  de- 
pendent upon  chronic  ulcer. 

The  stomach  should  be  emptied  before  the  operation  is  com- 
menced, after  the  patient  has  been  anesthetized,  with  the  stomach 
tube.  The  stomach  is  reached  through  an  incision  in  the  middle  line 
commencing  just  below  the  ensif  orm  cartilage  and  reaching  down  to 
the  umbilicus. 

A  transverse  incision  is  made  in  the  constricted  part  of  the 
stomach,  penetrating  through  the  entire  thickness  of  the  stomach 
wall  and  reaching  from  one  pouch  into  the  other.  Bleeding  points 
are  clamped  and  ligated  with  catgut.  The  edges  of  the  incision  are 
then  drawn  apart  with  two  tenacula  which  are  hooked  in  the  edges 
of  the  incision,  about  the  middle,  so  that  the  transverse  incision  be- 
comes converted  into  a  vertical  one.  The  edges  of  the  incision  while 
they  are  held  thus  are  sutured  together :  first  with  a  sufficient  num- 
ber of  interrupted,  through-and-through  stitches  of  catgut  which 
close  the  opening,  and  then  with  one  or  two  rows  of  Lembert  sutures 
of  silk.  The  latter  may  be  interrupted  or  continuous  and  should  take 
a  good,  broad  bite  in  the  stomach  wall. 


264  ABDOMEN  AND  BACK. 

This  operation  is  probably  not  so  satisfactory  where  chronic 
ulcer  exists  as  the  operation  of  gastro-gastrostomy  combined  with 
gastrojejunostomy  as  described  in  the  next  succeeding  paragraphs. 

Gastro-gastrostomy. — The  establishment  of  an  artificial  commu- 
nication between  parts  of  the  stomach.  The  operation  is  done  for  the 
relief  of  symptoms  due  to  hour-glass  contraction,  the  result  of  cica- 
trization, etc.,  of  ulcer  affecting  the  body  of  the  stomach.  In  exag- 
gerated cases  the  stomach  may  be  found  separated  into  two  distinct 
pouches  communicating  with  one  another  through  an  opening  so 
constricted  as  barely  to  admit  the  end  of  the  finger.  The  object  of 
the  operation  is  to  provide  a  liberal  opening  between  both  pouches 
which  will  readily  permit  the  discharge  of  the  stomach  contents  from 
the  proximal  into  the  distal  pouch  and  at  the  same  time  avoid  the 
passage  of  the  foodstuffs  over  the  ulcerated  area.  Under  these  favor- 
able conditions  ulcers  will  often  heal  rapidly. 

The  stomach  (proximal  pouch)  should  be  emptied  with  the 
stomach  tube  immediately  before  operating  and  after  the  patient 
has  been  anaesthetized  or,  if  this  has  not  been  done,  then,  when 
the  stomach  is  exposed,  the  contents  may  be  expressed  from  the 
stomach  into  the  duodenum.  The  incision  is  placed  in  the  middle 
line  commencing  about  one  inch  below  the  tip  of  the  ensif  orm  process 
and  reaching  downward  to  the  umbilicus;  it  can  be  still  further 
lengthened  if  necessary. 

After  the  abdomen  has  been  opened  the  stomach  is  sought.  It 
may  be  found  separated  into  two  pouches  of  nearly  equal  size  or  the 
upper,  cardiac  pouch  may  be  quite  small  and  concealed  above,  under- 
neath the  ribs.  Care  must  be  exercised  in  dealing  with  adhesions. 
The  stomach  may  be  adherent  to  the  anterior  abdominal  wall,  and 
the  breaking  down  of  these  adhesions  may  show  a  perforation  lead- 
ing into  the  stomach;  this  may  be  closed  by  infolding  all  of  the 
ulcerated  area  and  the  application  of  one  or  two  rows  of  Lembert 
sutures.  The  operator  should  not  be  precipitate  in  breaking  down 
adhesions  between  the  stomach  and  the  adjacent  organs,  especially 
the  pancreas  and  liver;  it  is  well  in  most  cases  not  to  disturb  these 
adhesions,  as  at  times  they  serve  to  close  up  an  opening  into  the 
stomach,  the  result  of  deep  ulceration. 

The  two  pouches  of  stomach  are  drawn  into  the  abdominal  in- 
cision or,  if  possible,  outside  upon  the  abdomen  and  after  pads  have 
been  properly  arranged  to  protect  the  peritoneal  cavity  the  anasto- 
mosis is  made  in  a  manner  similar  to  that  described  in  gastro-jejunos- 


OPERATIONS  UPON  THE  STOMACH.  265 

tomy.  The  two  pouches  are  joined  together,  side  by  side,  with  a 
continuous,  non-penetrating  silk  suture  carried  in  a  straight  cambric 
needle.  The  parts  should  be  united  thus,  in  a  straight  line,  for  a 
distance  of  two  and  one-half  or  three  inches  if  possible.  This  line 
of  suture  forms  the  posterior  half  of  the  "outside  serous  ring."    An 


Pig.  113. — Gastro-gastrostomy.  The  two  stomach  pouches  have  been 
joined  together  with  a  row  of  continuous  Lembert  sutures  and  each  has  been 
incised. 

incision  is  then  made  into  each  pouch  from  two  to  two  and  one-half 
inches  long,  parallel  with  and  about  one-quarter  inch  distant  from 
the  line  of  suture  that  has  been  applied.  These  incisions  should  be 
shorter  than  the  line  of  suture.  The  contiguous  margins  of  the 
two  openings  are  then  united  to  each  other,  all  around,  with  a  con- 
tinuous penetrating  suture  of  catgut.    After  this  line  of  suture  has 


266  ABDOMEN  AND  BACK. 

been  completed,  the  edges  of  the  openings  having  been  joined  to 
each  other  all  around,  the  needle,  carrying  the  thread  of  the  first 
non-penetrating  Lembert  suture  and  which  was  temporarily  laid 
aside,  is  again  taken  in  hand  and  the  anterior  half  of  the  non-pene- 
trating suture — "outside  serous  ring" — is  applied.  This  serves  to 
bury  the  penetrating  catgut  sutures  that  unite  the  edges  of  the 
openings  in  both  pouches  and  thus  completes  the  anastomosis.  The 
parts  are  wiped  clean  with  a  moist  bichloride  pad  followed  by  one 
wet  in  saline  solution  and  returned  into  the  abdomen.  One  should 
carefully  investigate  the  condition  of  the  pylorus,  and  if  any  con- 
striction is  discovered  a  gastrojejunostomy  should  be  performed,  in 
addition  to  the  gastro-gastrostomy,  the  junction  being  made  between 
the  distal,  pyloric,  pouch  and  the  upper  part  of  the  jejunum. 

The  abdominal  incision  is  closed  with  a  sufficient  number  of 
interrupted  silk  or  silk-worm  gut  sutures  including  all  the  layers, 
especially  the  parietal  peritoneum;  or  the  edges  of  the  peritoneum 
may  be  united  with  a  continuous  suture  of  catgut  and  the  other 
layers  with  silk,  etc. 

For  the  relief  of  hour-glass  contraction  where  the  presence  of 
adhesions  precludes  the  performance  of  a  gastro-gastrostomy,  a  gas- 
trojejunostomy may  be  made  between  the  proximal,  cardiac,  pouch, 
and  the  intestine.  The  operator  must  be  certain  to  secure  this  part 
of  the  stomach;  it  may  be  the  smaller  of  the  two  pouches  and  con- 
cealed beneath  the  ribs. 

Gastrectomy. — Excision  of  the  stomach,  may  be  partial  or  com- 
plete.   The  partial  may  be  either  atypical  or  cylindrical. 

Partial  Atypical  Gastrectomy. — Excision  of  a  limited  portion  of 
the  wall  of  the  stomach,  without  interruption  of  the  continuity  of 
the  organ;  for  non-malignant  ulcer  (see  also  gastrotomy  for  bleed- 
ing ulcer).  The  operation  is  indicated  in  those  cases  where  the 
ulcerated  area  is  limited  and  accessible. 

The  stomach  is  exposed  through  an  incision  in  the  linea  alba. 
Adhesions  that  are  encountered  are  gently  broken  down  with  the 
fingers  and  the  diseased  portion  brought  into  view  and  excised.  A 
diseased  area  of  the  posterior  wall  may  be  excised  from  within  the 
stomach,  working  through  an  opening  made  in  its  anterior  wall,  or 
else  this  portion  of  the  stomach  may  be  made  accessible  by  tearing 
through  the  gastro-colic  ligament  or  through  the  transverse  meso- 
colon. The  opening  that  remains  in  the  stomach  after  the  ulcerated 
area  has  been  excised  is  closed  with  a  through-and-through  suture  of 


OPERATIONS  UPON"  THE  STOMACH.  267 

catgut,  which  is,  in  turn,  reinforced  and  buried  by  a  continuous 
Lembert  suture  of  silk.  The  through-and-through  suture  controls 
the  bleeding  from  the  edges  of  the  stomach  wound.  Spurting  vessels 
may  be  clamped  and  ligated  with  catgut.  Mitchell  has  suggested 
that  simple  infolding  of  the  diseased  area  without  excision  would 
answer  very  well  in  many  of  these  cases. 

This  plan  of  excision  of  the  ulcer  can  only  be  applied  to  those 
cases  where  the  diseased  portion  of  the  stomach  can  be  made  ac- 
cessible. It  would  be  rather  more  difficult  to  follow  this  method  of 
treatment  if  the  ulcer  involved  the  posterior  wall  or  in  cases  of  deep 
ulceration  with  firm  adhesions  between  the  stomach  and  adjacent 
organs, — liver,  pancreas,  etc.  Under  these  conditions  the  operator 
might  wisely  content  himself  with  a  gastrojejunostomy.  It  would 
probably  be  advisable  in  all  these  cases  to  establish  a  gastrojejunos- 
tomy in  addition  to  excising  the  ulcerated  area,  etc.,  because  stenosis 
of  the  pylorus  is  associated  with  the  condition  of  chronic  ulcer  in  a 
considerable  number  of  cases. 

Partial  Cylindrical  Gastrectomy. — Eesection  of  an  entire  seg- 
ment of  the  stomach.  May  be  of  the  pyloric  portion  only,  pylo- 
rectomy;  or  the  pylorus  and  a  considerable  part  of  the  body  of  the 
stomach  may  be  resected,  the  partial  gastrectomy  of  Hartmann, 
Mayo,  and  Moynihan. 

Ptlorectomt. — This  operation  has,  until  recently,  been  the 
routine  one  practiced  for  operable  cases  of  malignant  disease  of  the 
pylorus;  but  in  the  light  of  recent  experience  it  would  seem  that  the 
more  extensive  operation  of  Hartmann  or  of  Mayo  is  to  be  preferred 
in  all  cases  of  malignant  disease  of  the  stomach  even  if  the  condition 
is  apparently  still  confined  to  the  pylorus.  The  operation  of  py- 
lorectomy  is  indicated  in  some  cases  of  chronic  non-malignant  ulcera- 
tion involving  the  pyloric  portion  of  the  stomach. 

The  incision  is  placed  in  the  middle  line  and  should  be  suffi- 
ciently large,  10  to  15  cm.,  extending  from  the  ensiform  process 
down  to  the  umbilicus  or  beyond  this  point.  The  pyloric  end  of  the 
stomach  is  drawn  into  the  wound  and  well  surrounded  with  gauze 
pads  so  arranged  as  to  protect  the  abdominal  cavity  during  the  op- 
eration, and  the  left  lobe  of  the  liver  is  held  up  out  of  the  way  by 
an  assistant. 

Billroth's  First  Method. — The  first  step  in  the  operation  is  the 
detachment  of  the  pylorus  (diseased  part  to  be  excised)  from  the 
greater  omentum  (transverse  colon)  below  and  from  the  lesser  omen- 


268 


ABDOMEN  AND  BACK. 


turn  above.  "With  a  blunt-pointed  ligature  carrier,  armed  with  catgut 
or  fine  silk,  the  greater  and  lesser  omenta,  corresponding  to  the  dis- 
eased pylorus,  are  transfixed  and  tied  off  in  sections.  Each  ligature 
should  include  from  one  to  one  and  one-half  inches  of  the  omentum, 


Fig.  114. — Pylorectomy.  Anterior  edge  of  the  liver  is  lifted  up;  the  lesser 
and  greater  omenta  are  shown.  The  lesser  and  greater  omenta,  correspond- 
ing to  the  portion  of  the  stomach  that  is  to  be  excised,  have  been  ligated  in 
sections.  The  dotted  lines  indicate  the  line  of  section  through  the  stomach 
and  omenta.  Instead  of  being  applied  as  represented  in  this  picture,  the 
ligatures  may  b€  placed  double  and  the  line  of  incision  carried  between  them. 


and  should  be  applied  double  so  that  when  the  operator  divides  each 
segment  of  the  ligated  omentum,  he  may  do  so  between  the  ligatures. 
Usually  two  ligatures  will  suffice  for  the  lesser  omentum,  gastro- 
hepatic  ligament,  and  three  or  four  for  the  greater  omentum,  gastro- 


OPERATIONS  UPON  THE  STOMACH. 


269 


colic  ligament.  Instead  of  a  ligature  carrier  a  sharp-nosed  artery- 
forceps  may  be  used  to  pass  the  ligatures.  One  should  be  mindful 
of  the  location  of  the  common  bile-duct  and  the  portal  vein  in  the 
free  right  edge  of  the  lesser  omentum.  After  the  pylorus  (tumor) 
has  been  thus  separated,  cut  away,  from  its  omental  attachment  above 
and  below,  it  may  be  drawn  pretty  well  out  through  the  abdominal 
incision,  so  that  the  subsequent  steps  of  the  operation  may  be  exe- 
cuted with  more  ease. 

Before  excising  the  pylorus  (tumor)  compression  clamps  are  ap- 
plied about  the  stomach  and  duodenum  close  to  the  tumor.  One  is 
applied  to  the  stomach,  close  to  the  tumor,  reaching  from  the  lesser 


Fig.  115.—  Pylorectomy  (Billroth).  Dotted  lines  indicate  lines  of  section 
in  excising  diseased  pylorus.  XXX  represent  diseased  portion  that  is  to  be 
excised. 


curvature  to  the  greater  curvature,  and  another  is  placed  about  the 
duodenum,  also  rather  close  to  the  tumor.  The  stomach  is  then 
seized  by  an  assistant,  who  compresses  it  between  the  fingers  of  both 
hands,  grasping  it  just  beyond  the  place  where  the  compression  clamp 
is  applied,  in  order  to  prevent  the  escape  of  stomach  contents  when 
it  is  cut,  and  then  the  operator,  with  a  sharp  scissors,  cuts  across  the 
stomach  from  above  downward,  between  the  fingers  of  the  assistant 
and  the  compression  clamp. 

The  stump  of  the  pylorus  is  then  enveloped  in  a  compress  and 
turned  to  one  side,  the  clamp  preventing  any  leakage.  The  hemor- 
rhage from  the  cut  edge  of  the  stomach  is  controlled  by  catching 
the  bleeding  points  with  forceps;  any  spurting  arterial  points  should 


270 


ABDOMEN  AND  BACK. 


be  ligated  with  fine  silk  or  catgut;  the  hemorrhage  from  the  divided 
veins  ceases  when  the  suture  is  applied. 

The  opening  in  the  stomach  is  closed,  commencing  above  and 
working  downward  toward  the  greater  curvature,  first  with  a  con- 
tinuous stitch  of  silk,  which  includes  all  the  coats  of  the  stomach 
and  which  is  applied  with  a  long,  straight  needle.  Each  loop  of  the 
suture  is  drawn  fairly  tight.  The  lower  part  of  the  opening  in  the 
stomach  is  left  unclosed  for  a  sufficient  length  to  allow  for  the  in- 
sertion, later,  of  the  end  of  the  duodenum.  A  second  continuous 
Lembert  stitch  is  then  introduced,  which  inverts  and  buries  the  first 
line  of  suture.    Through  the  opening  left  below  some  strips  of  gauze 


Fig.  116.-^Billroth's  First  Method  of  Pylorectomy.  Diseased  portion  has 
been  excised  and  the  end  of  the  duodenum  sutured  to  the  end  of  the 
stomach. 

are  packed  into  the  stomach  to  prevent  leakage,  and  then,  enveloped 
in  a  compress,  it  is  temporarily  laid  aside. 

The  attention  of  the  operator  is  now  directed  to  the  duodenum. 
Its  contents  are  stripped  along,  and  a  second  compressor  clamp  ap» 
plied  to  it;  this  clamp  is  used  for  the  purpose  of  preventing  the 
escape  of  contents  when  the  duodenum  is  cut.  Instead  of  employing 
a  compressor  the  duodenum  may  be  compressed  between  the  fingers 
of  an  assistant;  but  the  assistant's  fingers  occupy  considerable  space, 
and  may  interfere  with  the  work  of  the  operator. 

The  duodenum  is  severed  close  to  the  first  compressor  clamp  which 
was  applied  to  it,  and  the  resection  of  the  pylorus  is  thus  accom- 
plished. The  end  of  the  duodenum  is  wiped  off  with  a  wad  of  wet 
bichloride  gauze. 


OPERATIONS  UPON  THE  STOMACH.  271 

The  protecting  gauze  pads  are  now  renewed  and  after  the  pack- 
ing has  been  removed  from  the  opening  that  has  been  left  in  the 
stomach  the  end  of  the  duodenum  is  sutured  into  this  opening. 
There  is  first  applied,  with  a  curved  surgeon's  needle,  a  continuous 
silk  suture ;  this  should  be  applied  from  within  so  that  the  raw  edges 
will  be  turned  inward  and  present  toward  the  interior  of  the  gut. 
This  line  of  suture  should  include  all  the  coats,  take  a  good  bite, 
and  be  drawn  fairly  tight.  When  this  suture  has  been  completed, 
it  is  reinforced  by  a  second  row  of  outside  sutures,  continuous  and  of 
fine  silk,  which  includes  only  the  serous  and  muscular  coats  and 
buries  the  first  line  of  suture.  Special  care  should  be  taken  to  secure 
accurately  the  point  where  the  stomach  suture  meets  the  suture  that 
unites  the  stomach  and  the  duodenum. 

Billroth's  Second  Method. — This  operation  differs  from  the  one 
just  described  only  in  the  part  that  has  to  do  with  the  restoration 
of  the  continuity  of  the  alimentary  canal  and  is  to  be  preferred  to 
it  especially  if  the  stump  of  the  duodenum  is  short  or  fixed. 

After  the  pylorus  has  been  resected,  the  end  of  the  stomach  and 
the  end  of  the  duodenum  are  both  closed  completely  by  inversion 
and  suture  and  an  anterior  gastrojejunostomy  then  performed.  Ac- 
cording to  Billroth,  the  gastrojejunostomy  is  made  with  simple 
suture,  but  any  of  the  methods  described  (see  "Grastro-jejunostomy") 
may  be  employed  for  this  step  of  the  operation. 

Method  of  Kocher  (Eesection  of  the  Pylorus,  with  Gastro-duodenos- 
tomy). — Marked  success  in  Kocher's  hands. 

The  pyloric  tumor  is  exposed  through  a  long  median  incision 
and  then  separated  from  its  omental  attachments  as  described  above. 
After  the  pyloric  tumor  has  been  thus  isolated  compresses  are  packed 
about  it  to  protect  the  abdominal  cavity,  and  clamps  applied.  Upon 
the  stomach  side  of  the  tumor — in  order  to  include  the  whole  width 
of  the  stomach — two  clamps  may  be  necessary:  one  reaching  from 
above  downward  and  the  other  from  below,  or  one  long  clamp  may 
be  employed.  Upon  the  duodenum,  to  the  distal  side  of  the  tumor, 
a  clamp  is  likewise  applied;  parallel  with  this,  but  farther  along  on 
the  duodenum,  a  second  clamp  is  applied.    • 

The  duodenum  is  then  divided  with  sharp  scissors,  between  the 
two  clamps,  but  not  too  close  to  the  distal  clamp,  in  order  to  leave 
room  enough  for  necessary  manipulation  in  suturing,  etc.  The 
cut  edge  of  the  duodenum,  protruding  between  the  limbs  of  the 
clamp,  is  wiped  clean  of  intestinal  contents  with  a  wet  bichloride  pad 


272  ABDOMEN  AND  BACK. 

and  then  enveloped  in  sterile  gauze,  and  with  the  clamp  still  applied 
it  is  turned  to  the  right  and  held  against  the  right  edge  of  the  ab- 
dominal incision  hy  an  assistant.  The  clamp  which  compresses  the 
stump  of  the  duodenum  should  not  be  applied  too  tightly. 

We  next  turn  our  attention  to  the  stomach.  The  stomach  is 
seized  between  the  fingers  of  both  hands  by  an  assistant,  and  the 
pyloric  portion  cut  away  in  a  direction  from  above  downward,  be- 
tween the  clamps  and  the  assistant's  fingers,  and  removed.  The 
tumor  mass,  being  tightly  clamped  at  both  ends,  when  cut  away  does 
not  leak.  Bleeding,  spurting  points  in  the  cut  edge  of  the  stomach 
are  clamped  and  tied  with  fine  silk;  oozing  and  venous  hemorrhage 
stop  after  the  suture  has  been  applied.  The  margins  of  the  wound 
in  the  stomach  are  wiped  with  a  wet  bichloride  pad  and  brought 
together  throughout  their  entire  length  with  a  continuous  silk  stitch 
in  a  long,  straight  needle.  This  stitch  includes  all  the  coats,  and 
takes  a  good  bite;  this  sutured  edge  is  then  again  wiped  with  a  wet 
bichloride  pad  and  a  continuous  Lembert  stitch  of  fine  silk  is  applied, 
inverting  the  raw  edges  of  the  stomach  wound  and  completely  bury- 
ing the  first  line  of  suture. 

The  protecting  abdominal  pads  are  now  again  renewed,  and  we 
are  ready  to  proceed  with  the  last  step  of  the  operation:  the  union 
of  the  stump  of  the  duodenum  to  the  opening  that  is  made  in  the 
posterior  wall  of  the  stomach.  The  assistant,  still  holding  the  stom- 
ach, directs  its  sutured  end  forward  out  of  the  abdominal  incision 
so  that  its  posterior  surface  looks  toward  the  duodenum  which  is  held 
over  against  the  right  edge  of  the  abdominal  incision.  The  cut  end 
of  the  duodenum,  with  the  compressor  clamp  still  applied,  is  joined 
to  the  posterior  wall  of  the  stomach  by  a  continuous,  stitch  of  fine 
silk,  which  is  applied  with  a  cambric  needle  and  which  corresponds 
to  the  posterior  half  of  the  circumference  of  the  duodenum  as  it 
protrudes  from  the  clamp.  This  suture  catches  the  duodenum  just 
beyond  its  cut  edge.  It  does  not  pass  through  the  entire  thickness 
of  the  duodenum,  but  catches  only  the  serous  and  muscular  coats 
of  the  duodenum  and  the  corresponding  coats  of  the  stomach.  It 
forms  the  posterior  half  of  the  "outside  serous  ring*'  suture.  The 
needle,  still  carrying  the  thread,  is  then  laid  aside  until  it  is  wanted 
later  to  complete  this  "outside  serous  ring"  suture.  The  end  of  the 
duodenum  is  sutured  to  the  posterior  wall  of  the  stomach  about  one 
inch  distant  from  the  sutured  edge  of  the  latter. 


OPERATIONS  UPON  THE  STOMACH. 


273 


The  clamp  is  now  removed  from  the  duodenum,  the  hemorrhage 
controlled,  and  any  escaping  contents  sponged  away,  finally  wiping 
the  margin  with  a  wet  bichloride  pad.  An  opening  is  then  made  in 
the  stomach  of  a  size  to  correspond  with  the  end  of  the  duodenum. 
This  should  be  placed  one-fourth  inch  from  the  line  of  suture  by 


Fig.  117.— Pylorectomy  (Eocfter).  Stump  of  the  duodenum  has  been  joined 
to  the  posterior  wall  of  the  stomach  by  a  row  of  continuous  Lembert  sutures. 
Opening  has  been  made  in  the  stomach  to  receive  the  end  of  the  duodenum. 


which  the  duodenum  is  already  joined  to  the  wall  of  the  stomach. 
The  edge  of  the  duodenum  stump  is  then  sutured  all  around  to  the 
edge  of  the  opening  in  the  stomach,  with  a  curved  needle  and  silk, 
this  being  a  continuous  stitch  applied  from  within,  and  including  the 
whole  thickness  of  the  wall  of  each  organ  and  taking  a  good  bite,  so 
that  the  raw  edges  of  the  parts  look  inward  toward  the  lumen  of  the 


274  ABDOMEN  AND  BACK. 

gut.  When  the  parts  have  been  thus  united  all  around,  the  first 
needle,  which  was  temporarily  laid  aside,  is  again  taken  in  hand, 
and  the  Lembert  suture  which  is  to  form  the  anterior  half  of  the 
"outside  serous  ring"  is  applied  and  the  union  between  the  duo- 
denum and  stomach  is  complete.  Before  the  serous  surfaces  are 
apposed  they  should  be  swabbed  with  a  moist  bichloride  pad. 

The  protecting  pads  are  finally  removed  and  the  abdominal  in- 
cision closed.  With  a  continuous  catgut  stitch  the  edges  of  the 
peritoneum  are  coapted,  and  with  several  interrupted  silk-worm  gut 
sutures — which  pass  through  the  skin,  muscle,  and  aponeurosis — the 
closure  of  the  abdominal  wound  is  completed. 

With  the  Murphy  Button. — Instead  of  using  the  suture  as  just 
described,  the  junction  of  the  end  of  the  duodenum  and  stomach  may 
be  accomplished  by  means  of  a  Murphy  button.  This  procedure  is 
simple  and  quick  and  gives  satisfactory  results. 

Haetmann's  Method  of  Gastrectomy. — The  partial  gastrec- 
tomy, according  to  the  method  of  Hartmann,  is  performed  for  cancer 
of  the  pyloric  portion  of  the  stomach,  and  is  based  upon  the  normal 
arrangement  of  the  lymphatics  of  the  stomach.  It  consists  of  resec- 
tion of  the  pylorus  and  part  of  the  body  of  the  stomach  and  the 
adjacent  lymphatic  nodes.  The  pylorus  is  drained  chiefly  by  the 
lymphatics  that  terminate  in  the  nodes  situated  along  the  lesser 
curvature — along  the  course  of  the  gastric  artery — between  the  folds 
of  the  gastro-hepatic  omentum,  and  for  this  reason  cancer  originat- 
ing in  the  pylorus,  the  usual  site  of  the  disease,  spreads  more  rap- 
idly along  the  lesser  curvature  than  along  the  greater  curvature  (see 
Fig.  93),  involving  not  only  the  lymphatic  nodes,  but  also  affecting 
the  mucous  membrane  of  this  part  of  the  organ  early.  The  fundus 
is  not  affected  until  late  in  the  disease. 

In  this  operation  the  pylorus  and  body  of  the  stomach,  all  of 
the  lesser  curvature,  and  a  considerable  part  of  the  greater  curvature, 
together  with  all  the  adjacent  lymphatic  nodes  are  removed  in  one 
mass,  the  fundus  only  remaining;  the  continuity  of  the  alimentary 
canal  is  restored  either  by  a  gastro-duodenostomy  or  a  gastrojejunos- 
tomy. 

The  abdominal  incision  must  be  sufficiently  liberal,  reaching 
from  the  tip  of  the  ensiform  cartilage  downward  in  the  middle  line 
as  far  as  the  umbilicus  or  beyond  that  point.  If  still  more  room 
is  required  a  transverse  incision  may  be  added,  reaching  toward  the 
right  partly  or  completely  through  the  rectus  muscle.     The  hand  is 


OPERATIONS  UPON  THE  STOMACH. 


275 


introduced  into  the  abdomen  and  the  conditions  investigated.  As 
a  rule,  the  stomach,  tumor,  can  be  brought  out  through  the  incision. 
If  the  tumor  cannot  be  drawn  out  thus,  because  fixed  by  dense  ad- 
hesions and  by  the  extension  of  the  disease  to  the  surrounding 
organs, — pancreas,  liver,  spleen,  diaphragm,  etc., — then  the  case  is 


Fig.  118. — Doyen  Compression  Forceps. 

probably  not  a  suitable  one  for  this  radical  operation,  but  rather  for 
a  palliative  gastrojejunostomy.  Inflammatory  adhesions  that  are 
not  too  dense  may  be  broken  up  with  the  fingers.  The  liver,  etc., 
are  retracted  upward  by  the  assistant  and  the  stomach  seized  by 
the  operator  and  drawn  downward  and  the  index  finger  of  the  left 
hand  poked  through  the  gastro-hepatic  omentum.    In  this  way  the 


Fig.  119. — Hartmann  Compression  Forceps. 


operator  is  able  to  explore  the  posterior  wall  of  the  stomach,  the 
lymphatic  nodes  in  the  gastro-hepatic  omentum  along  the  lesser 
curvature,  and  also  locate  the  gastric  artery  where  it  approaches  the 
stomach  near  the  cardiac  end  of  the  lesser  curvature.  A  silk  liga- 
ture is  passed  around  the  gastric  artery  with  a  ligature  carrier  and 
tied.     The  pyloric  artery,  a  branch  of  the  hepatic,  may  also  be  tied 


276  ABDOMEN  AND  BACK. 

near  the  pyloric  end  of  the  lesser  curvature.  An  opening  is  then 
made  in  the  gastro-colic  omentum  near  the  lower  border  of  the 
stomach  and  through  this  opening  a  curved  forceps — Doyen — is  in- 
troduced and  applied  across  the  body  of  the  stomach,  the  tip  of  the 
forceps  reaching  up  beyond  the  lesser  curvature  close  to  the  point 
where  the  ligature  was  applied  to  the  gastric  artery.  A  second 
similar  compression  forceps  is  applied  across  the  stomach  to  the 
pyloric  side  of  this  first  forceps  and  also  reaching  from  the  greater 
to  the  lesser  curvature.  These  two  forceps  are  applied  very  tightly. 
The  left  gastro-epiploic  artery  may  be  ligated  close  to  the  compres- 
sion forceps.  This  vessel  is  found  running  from  left  to  right  near 
the  lower  border  of  the  stomach.  The  stomach  is  then  divided  be- 
tween the  two  compression  forceps  and  detached  along  its  greater 
curvature,  working  toward  the  right  as  far  as  the  pylorus.  The 
gastro-colic  ligament  is  ligated  in  sections,  each  section  being  tied 
double  and  the  ligatures  applied  sufficiently  far  away  from  the  border 
of  the  stomach  so  as  to  get  well  beyond  any  diseased  lymphatic  nodes 
that  may  be  present.  If  there  are  adhesions  to  the  transverse  meso- 
colon the  operator  must  be  careful  not  to  injure  the  arteria  colica 
media  nor  to  include  it  in  a  ligature,  because  this  vessel  supplies  the 
transverse  colon,  and  its  occlusion  would  result  in  gangrene  of  this 
part  of  the  bowel.  The  stomach  having  been  thus  divided  and  sepa- 
rated above,  along  the  lesser  curvature  from  the  gastro-hepatic  liga- 
ment and  below,  along  the  greater  curvature  from  the  gastro-colic 
ligament,  it  is  drawn  away  over  toward  the  right  and  there  are  thus 
exposed  the  posterior  aspect  of  the  stomach  and  pylorus  and  the 
head  of  the  pancreas,  which  is  covered  by  the  parietal  layer  of  peri- 
toneum that  is  reflected  upward  upon  the  posterior  abdominal  wall. 
The  gastro-duodenal  artery  is  now  sought  for  and  ligated.  This 
artery  is  a  branch  of  the  hepatic  and  is  found  behind  the  pylorus, 
passing  downward  between  the  head  of  the  pancreas  and  the  second 
part  of  the  duodenum.  It  is  necessary  to  tear  through  the  layer 
of  peritoneum  that  covers  the  anterior  surface  of  the  pancreas  in 
order  to  secure  the  vessel.  The  detachment  of  the  lymph  nodes 
that  accompany  this  vessel  and  its  main  branch,  the  gastro-epiploica 
dextra  and  which  are  located  behind  and  below  the  pylorus,  is  accom- 
plished without  much  difficulty  or  hemorrhage.  Two  straight  com- 
pression forceps  are  finally  applied  to  the  duodenum  and  the  gut 
divided  between  them,  and  thus  the  extirpation  of  the  diseased  portion 
of  the  stomach  is  accomplished. 


Fig.  120.— Gastrectomy  (Hartmann).  Gastric  artery  has  been  tied  and  the 
gastro-hepatic  ligament  divided.  The  stomach  has  been  divided  and  the 
portion  which  is  to  be  resected  with  the  damn  still  applied  is  turned  over 
toward  the  right  side  in  order  to  facilitate  the  ligation  of  the  gastro-duodenal 
artery.  A  portion  of  the  peritoneum  has  been  removed  from  the  anterior 
surface  of  the  head  of  the  pancreas  in  order  to  expose  this  vessel,  which  has 
been  picked  up  with  the  blunt  ligature  carrier. 


OPERATIONS  UPON  THE  STOMACH.  277 

The  raw  end  of  what  remains  of  the  stomach  is  closed  com- 
pletely with  a  line  of  suture  which  is  applied  before  the  forceps  is 
removed.  This  is  a  through-and-through  suture  of  catgut  and 
is  applied  close  to  the  blades  (upon  their  proximal  side).  At  every 
fourth  or  fifth  puncture  of  the  needle  a  ''hack-stitch"  should  be 
made  in  order  to  prevent  the  suture  from  drawing  and  producing 
the  "puckering-string"  effect.  This  line  of  suture  serves  to  close  the 
opening  in  the  stomach  and  at  the  same  time  controls  the  hemor- 
rhage. After  the  suture  has  been  introduced  the  forceps  is  removed. 
If  the  edge  of  the  stomach  beyond  the  line  of  the  suture  is  too 
broad  it  may  be  trimmed  off  with  the  scissors.  A  continuous  Lem- 
bert  suture  of  silk  is  then  applied.  This  row  of  Lembert  suture 
should  take  a  good,  broad  bite  in  the  wall  of  the  stomach  at  each 
puncture  and  should  completely  bury  the  first  through-and-through 
catgut  suture. 

After  the  end  of  the  stomach  has  been  thus  sutured  we  are 
ready  for  the  final  step  of  the  operation,  the  restoration  of  the  con- 
tinuity of  the  alimentary  canal.  This  is  accomplished  either  by 
uniting  the  cut  end  of  the  duodenal  stump  to  a  new  opening  which 
is  made  in  the  posterior  wall  of  what  remains  of  the  stomach,  gastro- 
duodenostomy  according  to  the  method  of  Kocher;  or  else  the  end 
of  the  stump  of  the  duodenum  is  closed  by  suture  and  a  communica- 
tion established  between  the  stomach. and  a  coil  of  the  jejunum — ■ 
a  gastrojejunostomy.  The  choice  between  these  two  procedures 
will  depend  upon  the  mobility  and  length  of  the  stump  of  the  duo- 
denum, the  preference  being  given  to  the  gastro-duodenostomy  if 
the  conditions  will  permit. 

If  a  gastro-duodenostomy  is  decided  upon,  this  is  established  by 
sewing  the  end  of  the  stump  of  the  duodenum  into  an  opening  made 
for  the  purpose  in  the  posterior  wall  of  the  stomach  according  to  the 
method  of  Kocher,  for  details  of  which  see  page  271. 

If  the  conditions  are  unfavorable  to  the  performance  of  the 
gastro-duodenostomy,  if  the  stump  of  the  duodenum  is  too  short  or 
fixed  and  cannot  therefore  be  brought  up  into  apposition  with  the 
stomach,  then  the  continuity  of  the  alimentary  canal  may  be  re- 
established through  a  gastrojejunostomy.  If  this  latter  plan  is 
adopted  the  end  of  the  duodenum  is  inverted  and  closed  in  a  manner 
similar  to  that  employed  in  closing  the  end  of  the  stomach;  first  with 
a  through-and-through  suture  of  catgut  which  is  applied  before  the 
forceps  is  removed  and  this  reinforced  by  a  continuous  silk  Lembert 


278  ABDOMEN  AND  BACK. 

suture  which  inverts  the  end  of  the  duodenum  and  brings  serous 
surfaces  into  apposition.  The  gastrojejunostomy  is  then  made.  A 
coil  of  the  jejunum  very  close  to  its  origin  is  selected  and  this  is 
sewed  to  the  posterior  wall  of  the  stump  of  the  stomach.  According 
to  this  plan  of  performing  a  gastrojejunostomy  the  attached  coil  of 
jejunum  is  so  short  that  there  is  no  afferent  limb  and  therefore  no 
receptacle  in  which  the  bile  and  pancreatic  juices  can  accumulate, 
and  give  rise  to  the  phenomena  of  the  "vicious  circle."  (See  "Gastro- 
jejunostomy," page  325.) 

Mato's  Method  of  Gasteectomt.  —  This  operation  is  based 
upon  the  same  anatomical  lines  as  that  of  Hartmann  and  is  indicated 
in  cases  of  malignant  disease  of  the  pylorus. 

The  incision  is  made  in  the  linea  alba  reaching  from  a  point  just 
below  the  ensiform  cartilage  downward  to  the  umbilicus  or  beyond 
that  point  if  necessary. 

After  the  stomach  has  been  exposed  the  vessels  that  supply  it 
are  ligated  double  and  divided  between  the  ligatures.  The  gastric 
artery  is  tied  first;  the  finger  is  thrust  through  the  gastro-hepatic 
ligament  and  the  vessel  secured  near  the  cardiac  end  of  the  lesser 
curvature.  The  ligature  is  applied  with  a  blunt  carrier,  tied  double, 
and  the  vessel  divided  between  them.  The  pyloric  artery,  which  is  a 
branch  of  the  hepatic,  is  next  secured,  tied  double,  and  divided;  it 
is  found  near  the  pyloric  end  of  the  lesser  curvature.  Between  these 
two  points  the  lesser  omentum,  gastro-hepatic  ligament,  is  tied  off  in 
several  sections;  each  section  is  tied  double  and  divided  betweeu 
the  ligatures.  The  fingers  are  then  passed  down  behind  the  pylorus, 
raising  the  pylorus  and  gastro-colic  ligament  away  from  the  transverse 
colon,  and  the  gastro-epiploica  dextra  is  secured,  tied  double,  and 
divided.  The  gastro-epiploica  sinistra  is  next  ligated;  it  is  found  at 
the  lower  border  of  the  stomach,  passing  from  left  to  right.  The 
gastro-colic  ligament  between  the  points  where  the  gastro-epiploica 
dextra  and  sinistra  have  been  ligated  is  tied  off  in  several  sections, 
each  section  being  tied  double  and  divided  between  the  ligatures; 
the  ligatures  are  placed  sufficiently  far  away  from  the  stomach  so  as 
to  get  well  beyond  any  diseased  lymph  nodes,  etc.  In  this  way  the 
entire  blood-supply  of  that  portion  of  the  stomach  which  is  to  be 
resected  is  cut  off.  Care  must  be  exercised  to  avoid  the  arteria  colica 
media  when  applying  the  ligatures  to  the  gastro-colic  ligament.  This 
vessel  is  the  sole  medium  of  supply  to  the  transverse  colon,  and  if 
occluded  gangrene  of  this  part  of  the  bowel  would  result. 


OPERATIONS  UPON  THE  STOMACH.  279 

The  duodenum  just  beyond  the  pylorus  is  next  grasped  with 
two  straight  clamps  and  divided  between  these  with  the  actual  cau- 
tery. A  stump  of  about  one-fourth  inch  should  be  left  protruding 
from  between  the  blades  of  the  duodenal  clamp;  before  the  clamp 
is  removed  the  cauterized  end  of  the  duodenum  is  closed  with  a  con- 
tinuous overhand  suture  of  catgut.  A  non-penetrating  purse-string 
suture  of  silk  is  placed  in  the  wall  of  the  duodenum  about  three- 
fourths  inch  beyond  the  clamp.  The  clamp  is  then  removed  and  the 
cauterized  end  of  the  duodenum,  which  has  already  been  closed  by 
suture,  is  infolded  into  the  lumen  of  the  gut  and  the  purse-string 
drawn  tight  and  tied.    The  duodenum  is  thus  disposed  of. 

A  long  holding  clamp  is  next  applied  across  the  body  of  the 
stomach,  reaching  from  the  greater  curvature  up  to  the  lesser  curva- 
ture close  to  the  point  where  the  gastric  artery  was  tied.  The  blades 
of  this  holding  forceps  are  covered  with  rubber  tubing  and  are  ap- 
plied only  sufficiently  tight  to  retain  the  tissues  in  their  grasp.  A 
second  similar  forceps,  but  with  the  blades  bare,  is  applied  across 
the  stomach  fairly  close  to  and  parallel  with  the  rubber-sheathed 
forceps  and  clamped  very  tightly  so  as  to  prevent  leakage  when 
the  stomach  is  divided.  The  stomach  is  severed  between  the  two 
clamps  with  the  actual  cautery,  leaving  a  margin  of  one-fourth 
inch  protruding  between  the  blades  of  the  holding  clamp,  and  thus 
the  resection  of  the  diseased  portion  of  the  stomach  is  completed. 
The  margin  of  stomach  that  protrudes  between  the  blades  of  the 
forceps  may  be  secured  at  several  points  with  artery  forceps  in  order 
to  prevent  its  slipping  from  between  the  blades. 

The  cauterized  margin  of  the  stomach  that  protrudes  between 
the  blades  of  the  forceps  is  sutured  with  a  continuous,  overhand, 
button-hole  suture  of  catgut ;  this  suture  penetrates  the  entire  thick- 
ness of  the  protruding  edges,  commencing  above  at  the  lesser  curva- 
ture and  working  downward  to  the  greater  curvature  and  then  back 
again  as  far  as  the  lesser,  where  it  terminates  and  is  tied.  This  suture 
closes  the  opening  in  the  stomach  and  prevents  hemorrhage  from  its 
cut  edges.  After  the  end  of  the  stomach  has  been  sutured  the  hold- 
ing clamp  is  removed  and  if  there  are  any  bleeding  points  to  be  seen 
these  are  clamped  and  tied.  A  continuous  non-penetrating  suture  is 
then  applied  all  along  the  sutured  edge  of  the  stomach,  effectually 
burying  the  penetrating  catgut  suture  infolding  this  margin  and 
bringing  serous  surface  into  accurate  apposition  with  serous  surface. 
This  suture  is  of  silk  and  should  take  a  good,  broad  bite. 


280  ABDOMEN  AND  BACK. 

The  final  step  in  the  operation  is  the  restoration  of  the  con- 
tinuity of  the  gastro-intestinal  canal.  This  may  be  effected  prefer- 
ably by  making  a  gastrojejunostomy  either  anterior  or  posterior, 
with  suture  or  Murphy  button  according  to  the  conditions  that  pre- 
sent themselves  in  each  individual  case. 

If  in  doubt  or  if  the  parts  have  been  soiled  during  the  opera- 
tion drainage  may  be  provided.  For  this  purpose  a  plug  of  gauze 
wrapped  in  rubber  tissue  may  be  introduced,  its  end  reaching  just 
above  the  transverse  colon.  The  abdominal  incision  is  closed  with 
interrupted  penetrating  sutures  of  silk;  if  drainage  has  been  em- 
ployed the  lower  end  of  the  incision  is  left  open  to  permit  exit  of  the 
gauze  drainage  plug. 

Complete  Gastrectomy.  —  Extirpation  of  the  entire  stomach. 
First  case  by  Schlatter,  1897.  A  healthy  heart  is  essential  to  the 
success  of  this  operation.  The  operating  room  should  be  kept  warm 
and  the  patient  dressed  in  flannel  garments,  to  prevent  as  much  as 
possible  loss  of  body-heat  by  radiation.  The  stomach  should  be 
washed  out  immediately  before  the  operation  is  commenced,  after 
the  patient  has  been  anaesthetized. 

The  incision  is  best  made  in  the  linea  alba,  and  must  be  liberal, 
— from  six  to  seven  inches  in  length, — reaching  from  the  ensiform 
process  to  the  umbilicus  or  even  beyond  this  point. 

After  the  abdomen  has  been  opened  the  stomach  is  recognized 
and  examined,  and  search  made  for  secondary  deposits  in  the  liver, 
pancreas,  and  adjoining  lymphatic  glands. 

The  first  step  consists  in  the  isolation  of  the  stomach,  detach- 
ing it  from  the  greater  and  lesser  omenta  and  from  its  attachment 
to  the  spleen:  gastro-splenic  omentum.  In  many  cases  the  stomach 
can  be  drawn  almost  entirely  out  of  the  abdomen  and  under  these 
conditions  the  performance  of  the  operation  is  greatly  facilitated. 

Commencing  at  the  pyloric  end  of  the  stomach,  the  omenta 
are  tied  off  in  sections, — first  the  lesser  and  then  the  greater  omen- 
tum,— each  section  including  about  one  and  one-half  inches  of  the 
omentum  and  being  tied  double,  so  that  the  latter  can  be  divided 
between  the  ligatures.  In  ligating  the  lesser  omentum  the  liver  must 
be  drawn  up  out  of  the  way  and  the  stomach  pulled  down.  The  pres- 
ence of  the  common  bile-duct,  etc.,  between  the  layers  of  the  lesser 
omentum,  near  its  free  right  border,  should  not  be  forgotten.  The 
ligatures  are  passed  with  the  blunt  ligature  carrier.  After  the  lesser 
and  greater  omenta  have  been  ligated  as  far  as  the  middle  of  the 


OPERATIONS  UPON  THE  STOMACH.  281 

stomach  and  have  been  divided,  the  section  may  he  made  between 
the  pylorus  and  duodenum,  in  order  that  the  stomach  may  the  better 
be  drawn  down,  so  as  to  make  the  detachment  of  its  cardiac  end  less 
difficult;  or  else  one  may  wait  until  the  whole  length  of  the  lesser 
and  greater  omenta  has  been  ligated  and  cut  away  from  the  stomach 
before  this  division  is  made. 

The  omentum  should  be  divided  between  the  double  ligatures 
with  the  scissors,  cutting,  piece  by  piece,  from  one  ligature  hole  into 
the  next. 

After  the  stomach  has  been  detached  from  its  omentum,  along 
the  lesser  and  greater  curvatures,  we  are  ready  for  the  next  step  of 
the  operation;  the  excision  of  the  stomach.  The  stomach  is  divided 
first  at  its  pyloric  end,  if  this  has  not  already  been  done.  An  intes- 
tinal clamp  is  placed  about  the  duodenum,  about  one  and  one-half 
inches  from  the  pylorus,  and  a  clamp  about  the  pyloric  end  of  the 
stomach,  and  between  these  the  intestine  is  divided  with  the  scissors. 
Any  escaping  contents  are  caught  upon  a  gauze  pad,  and  the  end  of 
the  duodenum,  sterilized  and  wrapped  in  gauze,  and  with  the  com- 
pressor still  applied,  is  dropped  back,  temporarily,  into  the  abdomen. 

A  ligature  is  then  thrown  around  the  gastro-splenic  omentum; 
this  is  the  peritoneal  fold  that  reaches  from  the  fundus  of  the  stom- 
ach to  the  spleen,  and  through  it  the  vasa  brevia  pass  to  the  stomach. 
This  ligature  is  applied  double  so  that  we  may  divide  between  the 
two.  Special  pains  should  be  taken  to  secure  the  vessels  in  the 
gastro-splenic  omentum,  leaving  the  ligature  long  that  the  pedicle 
may  be  drawn  forward,  so  that,  if  necessary,  the  individual  vessels 
may  be  secured  with  additional  ligatures. 

To  reach  the  oesophagus  the  stomach  must  be  pulled  well  down- 
ward. An  intestinal  compressor  is  placed  about  the  oesophagus  a 
short  distance  below  the  diaphragm,  and  a  clamp  about  the  oesoph- 
ageal end  of  the  stomach,  and  then  between  these  the  oesophagus  is 
divided  with  the  scissors.    The  stomach  is  thus  removed. 

After  the  stomach  has  been  excised  it  becomes  necessary  to 
restore  the  continuity  of  the  alimentary  canal,  either  by  joining  the 
end  of  the  duodenum  to  the  end  of  the  oesophagus,  cesophago-duo- 
denostomy,  or  else  by  inserting  the  end  of  the  oesophagus  into  the 
jejunum,  oesophago-jejunostomy. 

In  most  cases  the  cesophagiis  can  be  drawn  down  and  the  duo- 
denum sufficiently  mobilized  to  allow  of  its  being  brought  up  into 
apposition  with  the  end  of  the  oesophagus  without  undue  tension. 


282 


ABDOMEN  AND  BACK. 


In  this  case  the  parts  may  be  joined  together  with  a  Murphy  button 
No.  3  or  else  they  may  be  sutured,  end-to-end  (see  "End-to-End 


Fig.  121.— Gastrectomy.  OES,  stump  of  oesophagus;  D,  end  of  the  duo- 
denum. Dotted  lines  indicate  the  excised  stomach.  The  small  intestine 
(jejunum)  has  been  drawn  up  into  apposition  with  the  stump  of  the  oesoph- 
agus, as  in  cesophago-jejunostomy. 

Anastomosis").  If  the  button  is  used  for  the  purpose  of  restoring 
the  continuity  of  the  alimentary  canal,  then,  after  it  has  been 
inserted  and  the  compression  clamps  removed  from  the  duodenum  and 


OPERATIONS  UPON  THE  STOMACH.  283 

oesophagus,  a  row  of  outside  Lembert  sutures  should  be  applied  to 
make  the  junction  still  more  secure.  These  sutures  include  the  serous 
and  muscular  coats,  but  do  not  pass  through  the  mucous  membrane. 
If  unable  to  approximate  the  parts  as  described,  the  end  of  the 
duodenum  may  be  inverted  and  closed  with  a  double  row  of  sutures 
and  an  cesophago-jejunostomy  done,  the  end  of  the  oesophagus  being 
sutured  into  an  opening  which  is  made  in  the  small  intestine.  The 
upper  portion  of  the  jejunum  is  sought  in  the  upper  back  part  of 
the  abdominal  cavity, — to  the  left  of  the  body  of  the  second  lumbar 
vertebra, — and  a  coil  of  gut  about  eighteen  inches  beyond  this  point 
selected.  A  segment  of  this  coil  of  gut  about  eight  inches  long  is 
tied  off  with  tapes,  first  one  tape  is  tied  about  the  gut  and  then, 
after  the  contents  of  the  segment  have  been  stripped  along  with  the 
fingers,  the  other  tape  is  tied.  This  segment  of  gut  is  brought  up 
in  front  of  the  transverse  colon,  into  apposition  with  the  end  of  the 
oesophagus.  The  posterior  half  of  the  end  of  the  oesophagus  is 
sutured-  to  the  wall  of  the  coil  of  gut  with  a  row  of  continuous  Lem- 
bert sutures.  These  sutures  secure  the  wall  of  the  oesophagus  about 
one-fourth  inch  beyond  its  cut  edge,  and  include  the  serous  and 
muscular  coats,  but  not  the  mucous.  The  needle,  still  carrying  the 
thread,  is  then  discarded  temporarily,  and  an  incision  is  made  in  the 
gut  corresponding  in  length  to  the  size  of  the  opening  in  the  oesoph- 
agus. The  edge  of  this  opening  in  the  gut  is  sutured  to  the  edge  of 
the  oesophagus  all  around  with  a  continuous  silk  stitch  that  includes 
all  the  layers.  When  this  suture  has  been  completed  and  the  end 
of  the  oesophagus  thus  securely  fixed  to  the  opening  in  the  intestine, 
the  first  needle,  that  with  which  the  posterior  half  of  the  end  of  the 
oesophagus  was  joined  to  the  gut,  is  again  taken  in  hand  and  the 
anterior  half  of  the  "outside  serous  ring"  suture  applied.  It  is  well 
to  use  silk  exclusively  for  both  sutures  and  ligatures  in  this  opera- 
tion. The  abdominal  wound  is  closed  without  drainage.  It  might  be 
advisable,  in  addition,  to  establish  an  entero-anastomosis  between  the 
most  dependent  portions  of  the  two  limbs  of  the  attached  coil  of  gut 
in  order  to  insure  the  ready  escape  of  the  bile  and  pancreatic  juice 
from  the  proximal  into  the  distal  arm  of  the  gut. 

During  the  course  of  the  operation  the  solar  plexus  may  be 
considerably  molested,  and  at  the  time  that  the  oesophagus  is  severed 
both  pneumogastric  nerves  are  also  divided.  The  shock  is  therefore 
apt  to  be  marked,  and  should  be  counteracted  by  avoiding  as  much  as 
possible  loss  of  body-heat  and  by  administering  proper  stimulation. 


284  ABDOMEN  AND  BACK. 

The  division  of  the  pneumogastrics  leads  to  disturbance  of  the  heart's 
action;  it  becomes  very  greatly  accelerated.  An  attempt  should  be 
made  to  regulate  this,  probably  with  proper  doses  of  digitalis  hy- 
podermically.  For  the  first  few  days  the  patient  is  nourished  per 
rectum;  after  forty-eight  hours  fluids  may  be  given  per  mouth, 
first  small  quantities  of  water  and  then  broth,  milk,  etc.,  may  be 
added.  At  the  end  of  a  week  a  moderate  amount  of  solid  food  may 
be  taken  through  the  mouth. 

THE  SMALL  INTESTINE. 

The  Surgical  Anatomy  of  the  Small  Intestine.  The  Duodencjm 
is  the  first  part  of  the  small  intestine.  It  is  about  ten  inches  long 
and  commences  at  the  pyloric  end  of  the  stomach  and  ends  at  the 
jejunum.  Its  wall  is  moderately  thick.  It  is  usually  described  as 
consisting  of  three  parts. 

The  first,  or  ascending,  part  is  freely  movable,  continuous  with 
the  pylorus,  and  entirely  invested  by  peritoneum.  It  passes  from 
the  pyloric  end  of  the  stomach  upward  and  backward  toward  the 
right  as  high  as  the  level  of  the  twelfth  dorsal  vertebra;  it  reaches 
close  to  the  under  surface  of  the  liver,  with  which  it  is  connected 
by  the  so-called  ligamentum  hepatico-duodenale.  This  ligament  is 
simply  the  free,  thickened,  right  edge  of  the  lesser  omentum;  liga- 
mentum gastro-hepaticum.  Between  the  layers  of  the  lesser  omen- 
tum are  the  hepatic  artery,  portal  vein,  and  common  bile-duct,  the 
artery  ascending  to  the  liver,  and  the  duct  and  vein  descending  be- 
hind this  first  part  of  the  duodenum.  Between  the  layers  of  the 
lesser  omentum  the  artery  lies  to  the  left,  the  duct  to  the  right, 
and  the  vein  between  and  behind  both. 

The  duodenum  then  makes  a  turn  downward  along  the  right 
side  of  the  first  and  second  lumbar  vertebra,  lying  upon  the  front 
of  the  right  kidney,  with  the  head  of  the  pancreas  to  the  left  (i.e., 
internal  to  this  part  of  the  duodenum).  This  is  called  the  second 
part  of  the  duodenum.  It  differs  from  the  first  part  in  being  fixed 
to  the  posterior  wall  of  the  abdomen  and  in  not  being  completely 
surrounded  by  peritoneum,  but  simply  covered  by  the  peritoneum 
upon  its  front  surface,  and  therefore  when  we  look  for  this  part 
of  the  duodenum,  after  reflecting  the  transverse  colon  and  the  great 
omentum  upward,  it  is  not  to  be  seen,  and  is  only  exposed  to  view 
after  the  peritoneum  which  covers  its  anterior  surface  has  been  cut 


SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINE.  285 

through.  The  common  bile-duct  and  the  pancreatic  duct  open  into 
the  second  part  of  the  duodenum,  adjacent  to  the  head  of  the 
pancreas.  These  ducts  pass  obliquely  through  the  wall  of  the  duo- 
denum, and  join  with  each  other,  before  entering  the  gut  through 
a  single  common  orifice,  which  is  found  upon  the  inner  wall  of  the 
duodenum  in  the  center  of  a  papilla.  A  probe  may  be  passed  from 
this  part  of  the  duodenum  into  the  common  duct  or  into  the  pan- 
creatic duct.  Between  the  head  of  the  pancreas  and  the  second  part 
of  the  duodenum  in  the  injected  cadaver  there  may  be  seen  the  anas- 
tomosis between  the  superior  and  inferior  pancreatico-duodenalis 
arteries :  branches  derived  from  the  hepatic  and  superior  mesenteric, 
respectively. 

At  the  level  of  the  third  lumbar  vertebra  the  duodenum  makes 
another  turn,  passing  across  the  body  of  the  third  lumbar  from  the 
right  to  the  left  side  of  this  vertebra,  and  at  the  same  time  ascend- 
ing to  the  level  of  the  second  lumbar  vertebra.  This  is  known  as 
the  third  part  of  the  duodenum.  The  aorta,  etc.,  lie  behind  this  part 
of  the  duodenum,  and  the  head  of  the  pancreas  is  situated  above  it. 

Upon  the  left  side  of  the  body  of  the  second  lumbar  vertebra 
the  duodenum  is  fixed  to  the  vertebral  column  by  a  thickened  portion 
of  peritoneum;  this  fold  contains  some  unstriped  muscular  fibers, 
and  is  called  the  suspensory  ligament  of  the  duodenum,  the  ligament 
of  Treitz.  This  third  part  of  the  duodenum  also  is  covered  only  upon 
its  anterior  surface  by  the  peritoneum,  and  is  fixed  in  the  back  of 
the  abdomen,  in  common  with  the  pancreas,  by  this  layer.  This 
portion  of  the  duodenum  is  not  to  be  seen  until  after  the  layer  of 
peritoneum  which  covers  its  anterior  surface  and  conceals  it  from 
view  has  been  torn  through. 

The  whole  duodenum,  in  its  curved  course,  resembles  a  horse- 
shoe in  the  hollow  of  which  the  head  of  the  pancreas  is  received. 

The  Jejunum  and  Ileum,  about  twenty  feet  long,  make  up 
the  rest  of  the  tube  of  small  intestine,  and  are  the  direct  continua- 
tion of  the  duodenum,  terminating  in  the  caecum  in  the  right  iliac 
fossa. 

Upon  the  left  side  of  the  second  lumbar  vertebra,  where  the 
duodenum  ends  and  the  jejunum  begins,  the  intestinal  canal  becomes 
again  provided  with  a  complete  peritoneal  investment,  and  a  long 
mesentery. 

The  jejunum  forms  about  two-fifths  of  the  length  of  the  small 
intestine,  and  becomes  the  ileum  where  the  valvula?  conniventes, 


286  ABDOMEN  AND  BACK. 

which  characterize  its  inner  surface,  cease  to  exist.  It  is  thick  walled 
and  large  in  caliber,  and  therefore  resembles  somewhat  the  large 
intestine;  still,  it  is  readily  distinguished  from  this  part  of  the  gut 
by  the  absence  of  the  longitudinal  striae  and  appendices  epiploicse  and 
in  not  being  sacculated. 

At  its  commencement,  upon  the  left  side  of  the  second  lumbar 
vertebra,  the  jejunum  seems  to  project  directly  forward,  through  the 
parietal  peritoneum  which  lines  the  back  of  the  abdominal  cavity. 
This  appearance  is  due  to  the  fact  that  the  portion  of  the  gut, 
duodenum,  which  immediately  precedes  the  jejunum,  is  not  pro- 
vided with  a  mesentery;  it  lies  behind  the  peritoneum  and  is  covered 
by  it  upon  its  anterior  surface  only,  whereas  the  commencement 
of  the  jejunum  and  the  rest  of  the  small  intestine  are  provided 
with  an  investment  of  peritoneum,  which  completely  surrounds  them, 
and  a  mesentery,  which  suspends  them  to  the  back  of  the  abdomen, 
and,  therefore,  where  this  arrangement  commences,  the  gut  appears 
to  project  directly  forward  through  the  peritoneum  from  the  poste- 
rior wall  of  the  abdomen.  The  process  of  peritoneum  that  incloses 
the  first  part  of  the  jejunum  marks  the  commencement  of  the  mesen- 
tery. We  can  locate  this  first  portion  of  the  jejunum  by  reflecting 
the  great  omentum,  and  with  it  the  transverse  colon,  upward  out 
of  the  way,  and  then,  passing  the  hand  backward,  along  the  under 
surface  of  the  transverse  mesocolon  to  the  vertebral  column,  this  coil 
of  intestine  is  found  lying  just  to  the  left  of  the  body  of  the  second 
lumbar  vertebra.  An  attempt  to  draw  this  coil  of  gut  out  of  the 
abdomen  will  show  that  it  is  fixed  within  the  abdomen,  and  this  fact 
will  serve  to  identify  it  positively. 

The  ileum,  which  is  the  continuation  of  the  jejunum,  consti- 
tutes three-fifths  of  the  length  of  the  small  intestine.  It  becomes 
progressively  smaller  in  caliber  and  thinner  as  we  trace  it  toward  its 
termination  at  the  caecum,  where  its  wall  is  thinnest  and  its  caliber 
narrowest. 

The  jejunum  and  ileum  are  suspended  free  in  the  abdominal 
cavity  arranged  coil  upon  coil,  and  are  provided  with  a  complete 
peritoneal  envelope  and  a  long  mesentery  by  which  they  are  attached 
to  the  vertebral  column  in  the  back  of  the  abdomen. 

The  Mesentery  is  a  reflection  of  peritoneum  containing  some 
unstriped  muscular  fiber,  fat,  etc.;  it  serves  to  suspend  the  gut  in 
the  abdomen  and  at  the  same  time  supports  the  blood-vessels,  lym- 
phatics, nerves,  etc.,  in  their  course  to  and  from  the  small  intestine. 


z?^ 

^^^^^& 

"'^^^B 

^l||| 

--' 

Fig.  122. — Section  of  Intestine  and  its  Mesentery  to  show  Separation  of  its 
Layers  and  the  "Dead  Space." 


Fig.   123. —  Blood-supply  of  Small   Intestine.     Absence  of  free   anastomosis 
between  the  ultimate  vessels  may  be  noted. 


SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINE.  2S7 

The  mesentery  is  fan-shaped.  The  distal  border  is  very  long, 
corresponding  to  the  whole  length  of  the  small  intestine,  to  which 
it  is  attached;  the  proximal  border  is  short  and  is  fixed  to  the  ante- 
rior surface  of  the  vertebral  column,  reaching  from  the  left  side  of 
the  second  lumbar  vertebra,  where  the  duodenum  ends  and  the  jeju- 
num commences,  downward,  to  the  right  side  of  the  fifth  lumbar 
vertebra;  its  line  of  attachment  is  thus  oblique  from  the  left  side, 
above,  downward  and  to  the  right.  The  vertebral  edge  of  the  mesen- 
tery is  but  six  inches  long,  whereas  the  distal,  intestinal  edge  is  about 
twenty  feet  long,  and  in  order  to  accommodate  these  two  borders  to 
each  other  the  intestinal  end  of  the  mesentery  is  folded  and  folded 
upon  itself,  making  a  series  of  plaits. 

Where  the  two  layers  of  peritoneum  of  which  the  mesentery  is 
composed  meet  the  intestine,  they  diverge  and  surround  the  intes- 
tine in  a  sling-like  fashion,  the  intestine  being  entirely  invested 
except  for  the  small  "dead  space"  which  corresponds  to  the  separa- 
tion of  the  layers  of  the  mesentery  at  the  so-called  mesenteric  border 
of  the  intestine.  Here  the  mesentery  is  not  applied  directly  to  the 
surface  of  the  intestine,  but  is  separated  from  it,  leaving  a  small 
space — "dead  space" — where  the  serous  layer  does  not  form  part  of 
the  wall  of  the  intestinal  tube. 

The  Blood-supply  of  the  Small  Intestine  is  furnished  by 
the  superior  mesenteric  artery.  This  vessel  is  given  off  from  the 
anterior  aspect  of  the  aorta,  and  passes  forward  between  the  lower 
border  of  the  pancreas  and  third  part  of  the  duodenum;  it  is  located 
between  the  layers  of  the  mesentery,  and  courses,  in  a  curved  direc- 
tion downward  and  to  the  right,  toward  the  right  iliac  fossa.  The 
superior  mesenteric  is  a  short,  thick  trunk.  From  its  convex  side  it 
gives  off  branches  to  supply  the  whole  length  of  the  small  intestine; 
from  its  concave  side  it  gives  off  branches  to  the  large  intestine,  to 
the  caecum  and  vermiform  appendix,  ascending  colon,  and  transverse 
colon,  finally  anastomosing  with  a  branch  from  the  inferior  mesen- 
teric (see  below).  The  superior  mesenteric  vein  accompanies  the 
artery  and  its  branches,  and  behind  the  pancreas  joins  with  the 
splenic  to  form  the  portal  vein.  The  blood  in  the  portal  vein  is 
derived  from  the  intestine;  before  reaching  the  general  circulation 
it  passes  through  the  liver ;  it  leaves  the  liver  through  the  hepatic 
veins,  two  or  three  in  number,  which  empty  into  the  inferior  vena  cava. 

The  branches  of  the  superior  mesenteric,  which  supply  the 
small  intestine,  are  given  off,  as  already  mentioned,  from  the  con- 


288  ABDOMEN  AND  BACK. 

vex,  left,  side  of  the  artery.  These  branches  do  not  pass  direct  to 
the  intestine,  hut  anastomose  with  each  other,  forming  a  series 
of  arches.  From  this  set  of  arches  another  series  of  branches  is 
given  off,  and  thus  this  peculiar  anastomotic  arch  formation  con- 
tinues until  the  intestine  is  almost  reached;  finally  the  individual 
branches  from  the  ultimate  arches  are  distributed  to  the  wall  of 
the  intestine.  They  pass  to  the  intestine  from  between  the  layers 
of  the  mesentery,  where  these  separate  to  envelop  the  intestine — 
that  is,  at  the  mesenteric  border — through  the  so-called  "dead  space." 
After  the  ultimate  vascular  branches  reach  the  wall  of  the  gut  they 
do  not  communicate  freely  with  each  other;  therefore  each  segment 
of  gut  is  dependent  almost  exclusively  upon  one  or  two  definite  ves- 
sels for  its  nutrition  and  integrity.  The  same  arrangement  holds 
good  for  the  ultimate  veins.  If  several  of  these  ultimate  vascular 
branches  are  severed  close  to  the  gut  or  become  embolized  or  throm- 
bosed, we  are  apt  to  have,  as  a  result,  gangrene  of  the  corresponding 
segment  of  the  gut.  Wounds  of  the  intestine  at  the  mesenteric 
border  are  unfavorable  for  suture  on  account  of  the  absence  of  the 
serous,  peritoneal  covering,  at  this  part.  Wounds  at  the  mesenteric 
border  of  the  gut  almost  of  necessity  include  division  of  the  ultimate 
intestinal  arteries  and  veins,  and  therefore  interfere  seriously  with 
the  blood-supply  to  the  corresponding  part  of  the  gut. 

OPERATIONS  UPON  THE  SMALL  INTESTINE. 

Enterorrhaphy. — Suture  of  the  intestine  for  gunshot  and  stab 
wounds  and  for  perforations  due  to  ulceration,  typhoid,  chronic  duo- 
denal ulcer,  etc. 

For  Gunshot  and  Stab  Wounds. — These  injuries  are  fre- 
quently accompanied  by  hemorrhage  from  wounded  vessels  in  the 
mesentery.  The  severed  vessels  should  be  ligated  with  catgut.  If 
large,  and  especially  if  divided  close  to  the  gut,  it  is  well,  after 
ligating  the  bleeding  vessels,  to  resect  the  corresponding  segment  of 
the  gut,  as  such  injuries  are  very  apt  to  be  followed  by  gangrene 
of  that  part  of  the  intestine  which  is  dependent  for  its  supply  upon 
the  injured  vessels. 

The  incision  for  injuries  of  this  character  is  usually  made  in  the 
middle  line,  four  to  five  inches  long,  reaching  from  the  umbilicus 
downward  toward  the  symphysis.  The  incision  may  be  prolonged 
upward  toward  the  ensiform  cartilage,  passing  to  the  left  of  the  urn- 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  289 

bilicus.  The  operator  should  avoid  laying  the  abdomen  open  from 
the  ensiform  cartilage  down  to  the  symphysis  pubis  in  the  eager- 
ness of  his  search  for  wounds  in  the  gut.  If  it  becomes  necessary 
to  increase  the  length  of  the  incision  very  much,  the  edges  of  that 
portion  of  it  which  is  not  in  immediate  use  may  be  brought  together 
temporarily  with  a  few  interrupted  silk  sutures  which  pierce  the 
whole  thickness  of  the  abdominal  wall. 

After  the  abdomen  has  been  opened,  the  operator  should  make  a 
careful  and  systematic  examination  of  the  intestine  from  one  end  to 
the  other,  commencing  at  the  lowest  part  of  the  ileum,  where  it 
enters  the  caecum.  This  part  of  the  gut  should  be  sought  and  drawn 
out  upon  the  abdomen,  and  from  this  point  onward  the  small  intes- 
tine and  mesentery  should  be  carefully  inspected,  coil  after  coil  being 
drawn  out  and  examined  and  then  replaced,  continuing  thus  until 
the  upper  end  of  the  gut  has  been  reached. 

As  a  rule,  penetrating  gunshot  and  stab  wounds  of  the  abdomen 
are  accompanied  by  multiple  perforations  of  the  gut  and  mesentery, 
— may  be  as  many  as  fifteen  or  twenty, — and,  when  one  perforation 
in  the  gut  is  located,  usually  a  second  is  found  in  the  same  segment 
at  a  corresponding  point  opposite.  Each  time  a  projectile  passes 
through  the  gut  it  makes  two  wounds — one  of  entrance  and  one  of 
exit. 

Where  a  perforation  of  the  gut  is  located  the  mucous  membrane 
is  usually  found  protruding  and  tending  to  plug  up  the  opening, 
nature's  effort.  Here  we  pause,  replace  the  mucous  membrane,  wipe 
off  the  margins  of  the  opening  with  a  gauze  pad  moistened  with 
alcohol  followed  by  a  weak  bichloride  solution,  and  then  close  it  with 
two  or  three  interrupted  Lembert  sutures  of  fine  silk;  these  sutures 
should  be  placed  about  one-eighth  inch  apart,  and  care  should  be 
taken  to  invert  the  edges  of  the  wound  and  to  bring  the  serous  sur- 
faces into  close  apposition.  The  wounds  may  also  be  closed  with  a 
purse-string  suture  applied  in  a  circle  around  the  margin  of  the 
opening.  In  suturing  these  wounds  care  should  be  taken  not  to 
rediice  the  caliber  of  the  intestine  more  than  one-third. 

We  then  continue  along  in  the  search  for  further  wounds. 
Those  involving  the  mesenteric  border  of  the  gut,  especially  if  the 
adjoining  mesentery  is  torn,  are  unfavorable  for  suture;  in  the  first 
place,  the  serous  coat  on  this  part  of  the  gut  is  imperfect,  has  a 
"dead  space";  and,  in  the  second  place,  if  any  of  the  mesenteric 
vessels  are  divided  close  to  the  gut,  the  corresponding  segment  of 


290  ABDOMEN  AND  BACK. 

the  gut  is  apt  to  become  gangrenous;  therefore  it  is  wise,  in  many- 
cases,  to  resect  such  a  segment  of  gut  at  once. 

Bleeding  vessels  in  the  mesentery  should  be  clamped  and  tied 
with  plain  catgut. 

After  the  whole  length  of  the  small  intestine  has  been  explored 
the  surgeon  should  examine  the  entire  length  of  the  large  intestine, 
the  stomach,  and  the  bladder  for  perforations,  and  look  further  for 
hemorrhage,  which  might  indicate  wounds  of  the  liver,  spleen,  kid- 
neys, etc. 

Hemorrhagic  oozing  from  the  solid  viscera  is  usually  readily 
controlled  with  the  Paquelin  cautery  or  by  packing,  or  the  edges  of 
a  gaping  wound  may  be  brought  together  with  several  deep  catgut 
sutures,  although  these  tend  to  tear  through  if  much  tension  is  made. 
Any  spurting  vessels  in  the  solid  viscera  should  be  clamped  and  tied 
with  catgut. 

Having  thus  completed  the  examination  of  the  entire  length  of 
the  alimentary  canal,  etc.,  closed  all  wounds,  and  controlled  the 
hemorrhage,  the  whole  abdominal  cavity  may  be  flushed  out  with 
hot  saline  solution,  using  a  considerable  quantity — best  poured  from 
a  pitcher. 

During  the  search  for  wounds,  etc.,  the  gut  should  be  replaced, 
coil  after  coil,  as  fast  as  it  is  examined.  While  the  intestine  is  out- 
side the  abdomen  it  should  be  carefully  protected  with  hot  sterile 
towels,  which  may  be  wet  in  hot  saline  solution.  After  a  time  the 
wet  cloths,  if  not  repeatedly  wet  with  hot  water,  become  cooled; 
therefore  some  surgeons  prefer  dry  sterile  compresses  for  this  pur- 
pose. 

If  necessary  to  have  a  considerable  portion  of  the  length  of 
the  gut  outside  upon  the  abdomen,  it  should  be  supported  so  that  it 
does  not  drag  upon  the  mesentery;  this  should  be  avoided,  how- 
ever, as  much  as  possible,  as  the  shock  is  greatly  augmented  and  there 
may  be  some  difficulty  experienced  in  -returning  the  distended  coils 
of  gut  into  the  abdomen  again. 

If,  owing  to  the  distension  of  the  guts  with  gas,  it  becomes  dif- 
ficult to  replace  them  within  the  abdomen,  it  may  be  necessary  to 
puncture  them  in  order  to  allow  the  gas  to  escape.  In  doing  this  it  is 
probably  better  to  make  a  few  rather  large  openings  with  a  fairly  large 
aspirating  needle  or  a  scalpel  to  allow  gas  to  escape,  closing  them 
afterward  with  a  Lembert  stitch;  this  plan  is  probably  better  than 
making  numerous  small  punctures  with  a  fine  instrument. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  291 

The  abdominal  incision  should  be  carefully  closed,  first  sewing 
the  edges  of  the  parietal  peritoneum  together  with  a  continuous  No. 
2  catgut  suture;  then,  with  a  sufficient  number  of  interrupted  silk- 
worm sutures,  the  edges  of  the  skin  and  aponeurosis  are  brought 
together,  each  stitch  including  all  the  layers  of  the  abdominal  wall 
except  the  parietal  peritoneum. 

For  Typhoid  Perforation. — Perforation  of  the  bowel  at  the 
site  of  an  ulcer  may  occur  any  time  during  the  course  of  typhoid 
fever  from  the  first  week  up  to  the  termination  of  the  disease. 
Perforation  occurs  most  commonly  during  the  third  week.  It  is  more 
frequently  seen  in  adult  males  than  females  and  is  rather  rarely 
seen  in  children.     Operation  saves  about  25  per  cent,  of  the  cases. 

The  perforation  is  found  in  the  ileum,  usually  the  last  two  feet, 
in  about  80  per  cent,  of  the  cases;  in  about  12  per  cent,  the  perfora- 
tion is  located  in  the  large  intestine ;  and  in  about  5  per  cent,  in  the 
appendix.  The  perforation  is  usually  single,  but  they  may  be  mul- 
tiple. The  perforation  is  accompanied  by  peritonitis,  either  local  or 
general.  Operation  should  be  undertaken  as  soon  as  the  diagnosis 
is  made  and  in  case  of  doubt  an  exploratory  incision  may  be  resorted 
to.    This  can  be  done  under  cocain  if  desirable. 

Incision  is  made  in  the  right  linea  semilunaris  as  for  appendi- 
citis and  should  be  sufficiently  liberal  so  as  to  permit  of  proper  work 
— may  be  five  to  six  inches  long.  The  median  incision  from  the 
umbilicus  downward  is  sometimes  employed,  but  that  in  the  linea 
semilunaris  gives  much  better  access  to  the  portion  of  the  bowel 
which  is  usually  the  site  of  the  perforation.  When  the  abdomen  is 
opened  there  is,  as  a  rule,  an  escape  of  sero-purulent  fluid.  There 
may  or  may  not  be  some  inflammatory  adhesions  present  which  serve 
the  purpose  of  walling  off  the  damaged  portion  of  the  bowel  from  the 
general  peritoneal  cavity. 

The  csecuin  is  sought  and  drawn  into  the  incision  and  used  as 
a  guide  to  the  appendix  and  commencement  of  the  small  intestine. 
The  appendix,  if  perforated  or  seriously  effected,  is  removed.  Com- 
mencing at  the  caecum,  the  small  intestine  is  drawn  out,  coil  after 
coil,  and  carefully  inspected  and  wiped  clean  with  gauze  pads  or  it 
may  be  washed  with  salt  solution.  If  desired  this  investigation  may 
be  continued  until  the  entire  small  intestine  has  been  examined.  If 
the  coils  of  gut  are  not  immediately  returned  to  the  abdominal  cav- 
ity,' but  are  retained  outside  the  abdomen,  they  must  be  supported 
and  protected  with  hot,  sterile  towels. 


292  ABDOMEN  AND  BACK. 

The  perforations  vary  in  size  from  a  pin-head  to  a  fairly  large 
ragged  opening.  Usually  there  is  only  one  perforation,  but  there 
may  be  several.  The  hole  in  the  gut  is  closed,  without  paring  its 
edges,  with  non-penetrating  sutures  of  silk.  A  purse-string  suture 
may  be  applied  around  the  margin  and  the  opening  thus  closed  or 
one  or  two  rows  of  interrupted  Lembert  sutures  can  be  used.  These 
may  be  applied  in  mattress  fashion.  It  is  immaterial  whether  the 
opening  is  closed  in  a  direction  longitudinal  or  transverse  to  the 
long  axis  of  the  gut,  but  care  must  be  taken  not  to  reduce  the  caliber 
of  the  gut  too  much, — surely  not  more  than  one-third.  If  any  very 
thin  areas  are  encountered  during  the  examination  of  the  intestine 
it  might  be  advisable  to  take  a  stitch  or  two  in  such  portions  of  the 
gut  in  order  to  fortify  them  against  the  danger  of  perforation  later. 

If  the  opening  in  the  gut  can  be  closed  and  the  peritoneal  cavity 
thoroughly  cleansed  either  by  wiping  with  dry  gauze  pads  or  by 
irrigation  with  salt  solution,  it  may  be  permissible  to  close  the  ab- 
dominal incision  without  drainage.  In  doubtful  cases  it  is  well  to 
provide  for  drainage.  If  it  is  decided  to  use  drainage,  when  the  gut 
is  returned  to  the  abdomen  the  sutured  coil  is  placed  close  to  the 
abdominal  incision  and  gauze  strips  are  introduced  into  the  abdomen 
down  to  the  site  of  the  line  of  suture  in  the  bowel  so  that  in  case 
of  leakage  the  discharges  may  find  an  exit.  A  plug  of  strip  gauze  is 
also  introduced  into  the  abdomen,  reaching  well  down  into  the  pelvic 
cavity.  The  abdominal  incision  is  then  closed,  except  where  the 
drainage  strips  emerge,  with  interrupted  heavy  silk  sutures,  each  one 
of  which  penetrates  all  the  layers.  Drainage  may  be  facilitated  by 
keeping  the  patient  in  a  partly  sitting  posture  after  the  operation. 

If  the  gut  is  badly  damaged  or  presents  several  openings  close 
together  it  may  be  wise  to  resect  the  affected  portion  and  restore  the 
continuity  of  the  gut  by  an  end-to-end  anastomosis;  a  better  plan 
under  these  conditions  would  probably  be  to  draw  the  damaged  coil 
of  gut  out  of  the  abdomen  and  fix  it  to  the  edges  of  the  incision 
with  several  non-penetrating  sutures  of  silk  and  thus  establish  an 
intestinal  fistula. 

The  plan  of  treating  typhoid  perforation  by  suturing  the  dam- 
aged coil  of  gut  to  the  edges  of  the  abdominal  incision  with  several 
silk  sutures  so  as  to  make  a  faecal  fistula  has  been  practiced  with  very 
satisfactory  results  and  has  been  recommended  by  some  surgeons  as 
the  operation  of  choice  for  all  cases.  The  fistula  closes  spontane- 
ously or  may  be  closed  later  by  a  plastic  operation. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  293 

If  it  is  found  at  the  time  of  operation  that  the  soiling  of  the 
peritoneum  has  been  general  it  may  be  advisable  to  turn  the  entire 
small  intestine  out  of  the  abdomen  in  order  to  cleanse  the  peritoneal 
cavity  either  by  wiping  with  dry,  sterile  gauze  pads  or  else  by  irri- 
gating with  saline  solution;  after  the  intestines  have  been  treated 
in  a  similar  manner  they  are  returned  to  the  abdomen.  Drainage  is 
arranged  in  these  cases  as  already  indicated  above. 

Enterectomy. — Eesection  of  a  portion  of  the  gut  (small  intes- 
tine); the  length  of  gut  resected  may  vary  from  several  inches  to 
several  feet.  The  operation  is  performed  for  wounds  which  may 
not  be  safely  closed  by  suture;  for  those  associated  with  division  of 
the  mesenteric  vessels,  especially  if  they  are  divided  close  to  the 
intestine;  for  malignant  growths;  for  gangrene,  strangulation;  for 
fistula,  etc. 

The  incision  is  usually  made  in  the  middle  line,  four  or  five 
inches  long,  reaching  from  the  umbilicus  downward  toward  the  sym- 


Fig.  124. — Intestine  Compressor. 

physis.  The  portion  of  intestine  to  be  resected  should  be  gently 
freed  from  adhesions,  if  there  are  any,  and  brought  out  upon  the 
abdomen,  together  with  an  adjoining  portion  of  healthy  gut,  four  to 
six  inches  to  either  side  of  the  part  which  is  to  be  resected;  the  gut 
should  be  supported  upon  dry,  sterile  gauze  compresses,  some  of  which 
are  also  packed  into  the  abdominal  incision  to  protect  the  peritoneal 
cavity. 

In  order  to  prevent  the  escape  of  intestinal  contents  during 
the  operation,  two  gauze  strips  may  be  tied  around  the  gut,  one 
beyond  each  extremity  of  the  segment  which  is  to  be  excised.  An 
assistant  may  compress  the  gut  between  his  fingers  or  temporary 
intestinal  clamps  may  be  applied,  but  the  gauze  strips  are  probably 
more  convenient.  In  order  to  carry  the  gauze  strips  around  the  gut, 
a  thin-nosed  artery  forceps  is  thrust  through  the  mesentery  close 
to  the  gut,  and  with  this  the  end  of  the  gauze  strip  is  seized  and  pulled 
through.  One  strip  is  tied  and  the  contents  of  the  gut  gently  stroked 
along  with  the  fingers  beyond  the  second  strip,  and  then  this  is  tied 
also.     We  have  thus  a  fairly  empty  coil  to  operate  upon,  the  strips 


294 


ABDOMEN  AND  BACK. 


being  tied  just  tight  enough  to  prevent  the  re-entrance  of  contents. 
The  strips  should  be  applied  to  the  gut  at  a  sufficient  distance  beyond 
the  portion  which  is  to  be  excised  to  allow  convenient  working  space. 


Fig.  125. — Enterectomy.  A  loop  of  intestine  has  been  drawn  out  through 
the  abdominal  incision  and  tied  off  with  tapes.  The  mesentery  corresponding 
to  the  portion  of  gut  that  is  to  be  excised  has  been  tied  off  in  sections.  The 
dotted  lines  indicate  the  lines  of  section  through  the  mesentery  and  gut. 

We  then  proceed  to  separate  the  portion  of  gut  that  is  to  be  ex- 
cised from  its  mesenteric  attachment.  This  is  done  by  tying  the 
mesentery  off  in  segments,  each  ligature  including  about  one  inch 
of  the  length  of  the  mesentery;    the  ligatures  should  be  of  thin 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  295 

catgut  (No.  1  or  2),  and  each  tied  single  about  one  inch  away  from 
the  mesenteric  edge  of  the  gut.  These  ligatures  may  be  passed  either 
with  a  narrow-bladed  artery  forceps  or  a  blunt  ligature  carrier.  One 
must  be  careful  not  to  tie  off  a  greater  length  of  mesentery  than 
that  which  actually  corresponds  to  the  segment  of  gut  which  is  to 
be  excised,  because  gut  which  has  been  deprived  of  its  mesentery  is 
deprived  of  its  blood-supply  and  is  bound  to  slough.  The  surgeon 
should  rather  err  in  the  other  direction,  tying  off  a.  little  less  mesen- 
tery than  that  which  corresponds  to  the  length  of  the  segment  of  the 
gut  that  is  to  be  excised.  After  the  mesentery  has  been  thus 
tied  off,  the  segment  of  gut  that  is  to  be  excised  is  cut  away 
from  its  mesenteric  attachment,  using  the  straight  scissors  and 
cutting  between  the  ligatures  and  the  gut;  the  point  of  the 
scissors  should  be  introduced  into  the  openings  made  by  the  liga- 
tures, and  the  mesentery  cut  from  hole  to  hole,  and  thus  finally 
through  into  the  last  ligature  opening.  We  are  then  ready  to 
sever  the  gut,  and  this  is  done  with  long,  straight  scissors  that  will 
divide  the  gut  in  one  clean  sweep.  The  gut  should  be  divided 
straight  across  at  right  angles  to  its  long  axis  or,  still  better,  some- 
what obliquely,  so  that  the  segment  of  gut  excised  measures  rather 
more  upon  its  distal  border  than  upon  its  mesenteric  border.  Bleed- 
ing points  on  the  cut  edges  of  the  intestine  should  be  clamped,  but, 
as  a  rule,  these  do  not  require  ligation,  since  after  a  few  moments' 
pressure  or  after  the  ends  of  the  gut  have  been  sutured,  the  hemor- 
rhage usually  stops.  Spurting  arterial  points,  however,  should  be 
clamped  and  tied  with  fine  catgut.  Contents  that  escape  from  the 
ends  of  the  bowel  should  be  sponged  away,  and  care  should  be  taken 
that  the  pads  of  gauze  are  so  arranged  as  to  prevent  the  entrance  of 
any  of  this  material  into  the  abdominal  cavity. 

We  are  now  ready  to  restore  the  continuity  of  the  intestinal 
canal.  This  step  may  be  accomplished  by  any  one  of  the  several 
procedures  that  are  described  below.  It  will  be  observed  that  some 
of  the  methods  require  much  less  technical  skill  than  others. 

1.  End-to-end  anastomosis,  the  most  desirable. 
(a)  Suture. 
(b)  Invagination  and  suture  (Mounsell). 

(c )  Suture  by  Connell  method. 

(d)  Murphy  button. 

(e)  Laplace  anastomosis  forceps. 

(f)  OTIara  anastomosis  forceps. 


296  ABDOMEN  AND  BACK. 

2.  Side-to-side,  or  lateral,  anastomosis  ;  applicable  to  both  small 
and  large  intestine. 

(a)  Suture. 

(b)  Murphy  button. 

(c)  McGraw's  rubber  ligature. 

(d)  Laplace  anastomosis  forceps. 

(e)  O'Hara  anastomosis  forceps. 

3.  End  to  side;  this  method  is  used  to  join  the  ileum  to  the 
large  intestine  (see  "Kesection  of  Csecum")  and  to  join  the  end  of 
the  duodenum  to  the  stomach  after  pylorectomy  (see  "Pylorectomy, 
Kocher"),  etc. 

End-to-End  Anastomosis.  Sutuee. — The  ends  of  the  intestine, 
after  being  cleansed  and  swabbed  off  with  a  bichloride  pad,  are  joined 
together  all  around  with  a  continuous  suture.  This  suture  com- 
mences near  the  mesenteric  border  of  the  gut ;  it  is  continued  toward 
and  then  past  the  mesenteric  border  of  the  gut  and  finally  around  to 
the  point  where  it  commenced,  thus  uniting  the  two  segments  of  gut, 
end  to  end,  all  around.  This  suture  is  continuous  and  may  be  of 
fine  silk  or  catgut  (No.  2).  It  is  applied  with  a  curved  surgeon's 
needle,  sewing  from  within,  so  that  the  resulting  suture  line  presents 
into  the  lumen  of  the  gut.  This  suture  includes  all  the  layers  of 
the  wall  of  the  gut,  should  take  a  good,  broad  bite,  and  each  loop 
should  be  drawn  fairly  tight. 

In  beginning  the  suture,  near  the  mesenteric  border  of  the  gut, 
special  care  is  needed  in  passing  the  first  few  stitches  to  include  the 
serous  coat  in  each  bite  of  the  needle,  as  it  is  in  this  situation  that 
the  mesentery  splits  to  invest  the  intestine  and  is  here  not  applied 
close  down  upon  the  muscular  coat  of  the  gut;  therefore,  unless 
special  pains  are  taken  to  include  the  serous  coat  in  each  stitch,  this 
will  be  a  weak  spot,  slow  to  heal,  and  might  allow  leakage.  It  would 
be  advisable  before  commencing  the  suture  to  obliterate  the  "dead 
space"  with  a  suture  so  applied  as  to  draw  the  serous  coat  down  into 
close  contact  with  the  wall  of  the  gut  (see  Figs.  126  and  127). 

In  uniting  the  two  ends  of  the  gut  in  this  manner  the  last  few 
stitches  must  be  applied  interrupted,  but  they  should  be  so  tied  that 
the  sutured  edges  of  the  gut  will  be  inverted  and  look  inward  into  the 
lumen  of  the  gut,  and  that  the  knots  will  present  upon  the  inner 
aspect  of  the  united  intestine.  The  last  one  or  two  stitches  will, 
of  necessity,  have  to  be  applied  from  without,  but  this  will  not  pre- 
vent the  edges  of  the  gut  being  properly  inverted. 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


297 


After  the  junction  of  the  gut  has  been  thus  completed,  end  to 
end,  and  having  wiped  the  parts  immediately  adjacent  to  the  line  of 
suture  with  a  wet  bichloride  pad,  we  may  proceed  to  apply  a  second, 
continuous  Lembert  suture  of  fine  silk.  This  Lembert  stitch  is  in- 
troduced with  a  straight  cambric  needle,  and  includes  only  the  serous 
and  muscular  coats;  it  should  completely  bury  the  preceding  pene- 
trating stitch,  special  caution  being  used  to  appose  serous  surface 
to  serous  surface,  particularly  near  the  mesenteric  attachment. 

The  hole  which  is  left  in  the  mesentery,  after  the  segment  of 
gut  has  been  resected  and  the  ends  sutured,  should  be  closed  with 
a  continuous  catgut  stitch,  again  using  extra  care  to  bring  the  edges 
of  the  opening  close  together  near  the  surface  of  the  gut. 


Fig.    126.— Suture    to    Obliterate 
Space"  has  been  Inserted. 


'Dead        Fig.    127.— Suture    has    been    Tied 
"Dead   Space"    Obliterated. 


and 


The  constricting  strips  which  were  placed  around  the  gut  are 
removed  and  the  sutured  bowel  returned  into  the  abdomen. 

The  incision  in  the  abdomen  is  closed,  either  with  a  single  series 
of  interrupted  silk-worm  gut  sutures  which  include  the  whole  thick- 
ness of  the  abdominal  wall, -or,  better,  the  edges  of  the  parietal  peri- 
toneum may  be  brought  together  first  with  a  continuous  catgut  stitch, 
and  then,  in  addition  to  this,  the  other  layers  of  the  abdominal  wall 
united  with  a  sufficient  number  of  silk-worm  gut  sutures. 

MouNSELi/s  Method. — After  the  segment  of  gut  has  been  ex- 
cised as  above  described,  the  cut  ends  are  placed  close  together  edge 
to  edge  and  supported„outside  the  abdomen  upon  gauze  pads.  With 
a  moderately  large,  straight  needle  and  fairly  thick  silk  the  edges  of 
the  cut  ends  of  the  gut  are  fixed  to  each  other  at  four  different  points 
of  their  circumference  equidistant  from  one  another.     These  sutures 


298  ABDOMEN  AND  BACK. 

are  to  serve  simply  as  tractors.  The  first  is  applied  at  a  point  corre- 
sponding to  the  mesenteric  attachment,  the  second  at  a  point  directly 
opposite  this,  and  the  other  two  at  points  midway  between  these. 
Each  of  these  sutures  should  include  all  the  coats  of  the  gut,  special 
care  being  taken  to  catch  the  mucous  membrane  and  the  serous  coats ; 
the  suture  at  the  mesenteric  border,  particularly,  should  take  a  good 
hold  of  the  serous  coat  and  should  reach  well  upward  so  as  to  secure 
this  layer  and  draw  it  down  into  close  contact  with  the  wall  of  the 
intestine  and  thus  obliterate  the  "dead  space"  and  insure  proper 
inversion  of  the  serous  coat  at  this  point  (see  Figs.  126  and  127). 
Each  suture  is  applied  from  within  the  gut,  so  that,  when  tied,  the 
knot  will  be  upon  the  inner,  mucous  membrane  aspect  of  the  gut. 
As  each  of  these  four  tractor  sutures  is  passed,  it  is  immediately  tied 
and  one  end  cut  short,  leaving  the  other  end  long.  In  tying,  the 
sutures  should  not  be  tied  right  down  tight  upon  the  edges  of  the- 
gut,  but  rather  loosely,  so  that  afterward  they  may  be  readily  re- 
moved. 

In  one  or  the  other  segment  of  the  gut,  a  longitudinal  incision 
is  then  made.  This  incision  is  placed  opposite  the  mesenteric  bor- 
der, should  be  about  one  inch  long,  and  commences  about  one  and 
one-half  inches  distant  from  the  cut  edge  of  the  gut.  It  is  best  made 
by  picking  up  the  wall  of  the  gut  with  two  toothed  forceps,  and  be- 
tween these,  with  a  sharp,  straight  scissors,  a  clean-cut  incision  is 
made  through  the  whole  thickness  of  the  wall  of  the  gut.  Through 
this  incision  a  narrow  artery  forceps  is  passed  into  the  gut  and  the 
tails  of  the  four  tractor  sutures  seized  and  pulled  through,  thus 
drawing  the  ends  of  the  gut  after  them,  with  the  result  that  the  one 
segment  of  gut  is  invaginated  into  the  other,  their  serous  surfaces 
lying  in  contact  with  each  other  and  their  corresponding  edges  in 
apposition  all  around.  The  four  tractor  sutures  are  held  by  assist- 
ants and  put  somewhat  upon  the  stretch,  and  then  the  corresponding 
edges  of  both  segments  of  the  gut  are  ready  to  be  joined  by  suture. 
The  edges  are  sewed  together  with  a  quilting,  through-and-through 
stitch,  using  a  straight  needle  and  fine  silk.  This  suture  should  be 
applied  rather  more  than  one-eighth  inch  below  the  edges  of  the 
gut  so  as  to  leave  a  margin  that  wide  between  the  suture  line  and 
the  edges  of  the  gut.  The  stitches  should  be  placed  quite  close  to- 
gether (intervals  of  rather  less  than  one-eighth  inch  between  the 
needle  punctures)  and  each  stitch  should  be  drawn  fairly  tight.  In 
order  to  avoid  a  "puckering  or  purse-string"  effect  in  the  suture  a 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


299 


Fig.  128. — End-to-End  Anastomosis  (Mounsell).  The  ends  of  the  two  seg- 
ments have  been  joined  by  four  tractor  sutures,  the  ends  of  which  are  drawn 
out  of  an  opening  made  in  the  gut. 


Fig.  129.— Shows  How  One  Coil  of  Gut  is  Invaginated  into  the  Other 
by  Pulling  upon  the  Tractors. 


Fig.  130.— The  Two  Coils  of  Gut,  One  Invaginated  within  the  Other,  have 
been  Drawn  through  the  Incision  in  the  Gut  and  their  Edges  United  all 
Around  with  a  Through-and-Through  Suture. 


300  ABDOMEN  AND  BACK. 

"back-stitch"  should  be  taken  every  fourth  or  fifth  puncture.  The 
stitch  should  include  all  the  coats  of  the  gut,  special  pains  being 
taken  to  include  the  serous  coat,  particularly  at  the  mesenteric  border 
of  the  gut.  This  will  be  facilitated  by  having  applied  the  tractor 
stitch  at  the  mesenteric  border  as  above  described  so  as  to  catch  the 
serous  coat  high  up  and  thus  draw  this  layer  down  into  close  contact 
with  the  wall  of  the  gut  and  so  obliterate  the  "dead  space." 

After  the  edges  of  the  segments  of  the  gut  have  been  united  as 
above  described,  the  temporary  tractor  sutures  are  removed  and  the 
gut  restored  to  its  natural  position  by  reducing  the  invagination. 
The  incision  in  the  gut  is  closed  with  a  continuous  Lembert  stitch. 

All  around  the  circular  junction  of  the  segments,  after  swab- 
bing with  a  pad  moistened  with  alcohol,  followed  by  one  wet  with  a 
weak  bichloride  solution,  a  continuous  Lembert  stitch  of  fine  silk 
may  be  applied;  this  suture  still  further  inverts  the  edges  of  the 
gut  and  buries  completely  the  penetrating,  through-and-through 
suture.  This  additional  outside  line  of  suture  is  considered  unneces- 
sary by  most  surgeons,  especially  if  the  quilting  suture  has  been 
employed  and  has  been  accurately  applied. 

The  opening  which  is  left  in  the  mesentery,  after  the  segment 
of  gut  has  been  excised,  is  closed  with  a  continuous  catgut  suture, 
special  care  being  taken  to  make  the  union  accurate  close  to  the 
intestine.  The  gut  is  then  returned  to  the  abdominal  cavity  and 
the  opening  in  the  abdomen  closed. 

Connell  Method. — According  to  this  plan  a  through-and- 
through,  right-angled  suture  is  employed.  The  edges  of  the  two  ends 
of  the  gut  that  are  to  be  united  are  held  in  apposition  during  the 
application  of  the  suture  with  four  tractor  sutures.  The  first  tractor 
secures  the  edge  of  either  end  of  the  gut  at  its  mesenteric  border. 
In  introducing  this  suture  pains  should  be  taken  to  catch  the  edge 
of  the  mesentery  some  little  distance  away  from  the  wall  of  the 
gut  so  that,  when  it  is  drawn  tight,  it  will  pull  the  serous  layer  down 
into  close  contact  with  the  muscular  coat  and  thus  obliterate  the 
"dead  space"  between  the  mesenteric  layers  (see  Figs.  126  and  127). 
A  second  tractor  pierces  the  edge  of  each  segment  of  the  bowel 
at  a  point  a  little  more  than  halfway  between  the  mesenteric  border, 
where  suture  No.  1  has  been  introduced,  and  the  distal  border. 
Tractors  Nos.  3  and  4  each  catch  the  edge  of  the  corresponding  seg- 
ment of  the  bowel  at  a  point  the  same  distance  from  its  mesenteric 
border  as  suture  No.  2,  but  upon  its  opposite,  the  outer,  border. 


Fig.  131. — Connell  Suture.  The  four  tractor  sutures  have  been  placed  and 
the  edges  of  the  gut  sutured  together  for  the  first  third  of  their  circumfer- 
ence,— i.e.,  from  tractor  No.  2  to  No.  1. 


Fig.  132.— Connell  Suture.  The  side  tractors,  Nos.  3  and  4,  are  about  to 
be  brought  together  so  as  to  oppose  the  edges  of  the  gut  for  the  second  third 
of  their  circumference,  the  portion  between  tractor  No.  1  and  tractors  Nos.  3 
and  4. 


-Connell  Suture.     The  edges  of  the  gut  for  the  last  third  of 
their  circumference  are  sutured  together. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  301 

These  four  tractors  are  introduced  simply  for  the  purpose  of  facili- 
tating the  application  of  the  suture  that  is  to  unite  the  two  ends 
of  the  bowel.  They  are  of  silk,  and  as  they  are  drawn  taut  they 
convert  the  end  of  each  segment  of  the  gut  into  a  triangular-shaped 
opening.  It  will  be  noticed  that  tractors  Nos.  1  and  2  each  pierce 
corresponding  points  of  the  two  segments,  whereas  sutures  Nos.  3 
and  4  each  secure  the  edge  of  only  one  segment  of  the  bowel. 

The  second  step  of  the  operation  consists  in  suturing  the  ends 
of  the  two  segments  of  the  bowel  to  each  other  all  around.  This 
is  accomplished  with  a  through-and-through,  right-angled  suture. 
While  the  gut  is  steadied  by  tractors  Nos.  1  and  2,  held  by  the  as- 
sistant, the  opposed  edges  of  the  gut  are  sutured  together,  commenc- 
ing near  tractor  No.  2  and  working  toward  and  a  little  beyond  tractor 
No.  1  which  marks  the  mesenteric  border  of  the  gut.  In  this  wa}' 
the  union  between  the  two  ends  of  gut  is  accomplished  for  the  first 
third  of  their  circumference.  After  the  first  stitch  has  been  intro- 
duced the  thread  is  tied,  the  tail  of  the  suture  being  left  long. 

Tractor  No.  2  is  then  cut  away  and  traction  made  with  tractor 
No.  1.  At  the  same  time  tractors  Nos.  3  and  4  are  drawn  around 
so  as  to  approximate  the  corresponding  edges  of  the  two  ends  of 
the  gut  for  that  portion  of  their  circumference  which  is  included 
between  tractor  No.  1  and  tractors  Nos.  3  and  4.  With  the  same 
needle  and  thread  these  portions  of  the  edges  of  the  gut  are  then 
united,  working  from  tractor  No.  1  toward  and  a  little  beyond  trac- 
tors Nos.  3  and  4,  and  thus  the  edges  of  the  gut  are  united  for  the 
second  third  of  their  circumference.  The  line  of  suture  should  be 
placed  rather  less  than  one-quarter  inch  away  from  the  edges  of  the 
bowel  so  as  to  leave  a  margin  that  wide.  The  stitches  should  be 
placed  close  together — the  needle  punctures  less  than  one-eighth 
inch  apart — and  a  "back-stitch"  should  be  made  at  every  fourth  or 
fifth  puncture  in  order  to  fix  the  suture  and  avoid  the  "purse-string," 
or  puckering,  effect.  If  we  analyze  the  details  of  the  stitch  it  will  be 
noticed  that  in  order  to  make  each  complete  stitch  the  needle  must 
pierce  the  edges  of  both  segments  of  the  bowel.  Entering  upon  the 
mucous  aspect  of  one  segment,  it  goes  completely  through  the  whole 
thickness  of  the  walls  of  both  segments  and  emerges  upon  the  mu- 
cous aspect  of  the  second  segment.  In  making  the  next  succeeding 
stitch  it  will  be  observed  that  the  needle  is  again  entered  upon  the 
mucous  aspect  and  right  alongside  of  the  point  where  it  just  emerged 
in  completing  the  last  stitch;    it  penetrates  the  walls  of  both  seg- 


302  ABDOMEN  AND  BACK. 

ments  of  the  gut  and  emerges  again  upon  the  mucous  surface  of  the 
first  segment. 

The  remaining  tractors,  Kos.  1,  3,  and  4  are  removed  and  we 
then  proceed  to  suture  the  edges  of  the  bowel  for  the  last  third  of 
their  circumference.  As  this  must  be  done  without  the  assistance  of 
the  tractors  attention  must  be  given  to  the  detail  of  the  stitch.  The 
needle  is  thrust  through  the  edge  of  the  one  segment  of  the  gut, 
entering  upon  its  mucous  membrane  aspect  immediately  adjacent  to 
the  point  where  it  last  emerged,  and  then,  in  order  to  make  the  second 
half  of  the  stitch,  the  needle  is  carried  across  to  the  other  segment  of 
the  bowel  and  this  is  pierced  near  its  edge  penetrating  from  the 
serous  surface  and  emerging  upon  its  mucous  aspect.  To  make  each 
successive  stitch  the  needle  is  thrust  through  the  edge  of  the  same 
segment  of  the  bowel  and  just  alongside  of  where  it  last  emerged, 
penetrating  from  the  mucous  to  the  serous  surface,  then  across  to 
the  other  segment  of  the  bowel  which  it  pierces  from  the  serous 
to  the  mucous  surface.  As  each  stitch  is  introduced  the  thread  is 
drawn  tight.  Toward  the  end,  the  last  few  stitches  are  left  a  little 
slack  so  as  to  allow  sufficient  room  for  the  manipulation  that  is  neces- 
sary in  introducing  the  terminal  stitches.  The  last  puncture  of  the 
needle  as  it  completes  the  suture,  should  show  the  thread  emerging 
upon  the  mucous  membrane  aspect  of  the  gut  immediately  adjacent 
to  the  tail  that  has  been  tied  and  which  marks  the  commencment  of 
the  suture.  The  tail  of  thread  that  corresponds  to  the  termination 
of  the  suture  should  be  left  longer  than  the  tail  that  is  tied  and  which 
marks  the  commencement  of  the  suture  in  order  that  it  may  be  thus 
identified. 

The  last  step  of  the  operation  consists  in  tying  the  ends  of  the 
thread  so  that  the  knot  will  be  within  the  lumen  of  the  gut.  The 
end  of  a  narrow,  straight,  ligature  carrier  is  introduced  into  the 
bowel  between  the  stitches  at  a  distance  of  about  three-fourths  of 
an  inch  away  from  the  space  through  which  the  two  ends  of  the 
suture  emerge.  The  point  of  the  carrier  is  then  pushed  out  through 
this  space  (through  which  the  suture  ends  emerge)  and  the  ends  of 
the  suture  are  threaded  into  its  eye.  The  instrument  is  then  with- 
drawn pulling  the  tails  of  the  suture  after  it.  A  little  traction  is 
made  upon  the  longer  of  the  two  suture  ends  in  order  to  tighten  up 
the  slack  of  the  last  few  stitches.  The  ends  are  then  tied  and  cut 
short.  By  rolling  the  bowel  between  the  fingers  the  knot  will  be 
made  to  slip  into  the  lumen  of  the  gut. 


Fig.   134.—  Connell  Suture.     Ends  of  thread  about  to  be  drawn  through  an 
adjacent  space  between  two  stitches  for  the  purpose  of  tying  the  knot. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  303 

With  Murphy  Buttox. — Having  resected  the  gut  as  above  de- 
scribed, a  running  string  is  placed  in  the  edge  of  each  segment  of  the 
gut  which,  when  drawn  tight  and  tied,  puckers  the  end  of  the  gut  and 
grasps  the  button  about  its  shank,  leaving  the  flange  or  cup  of  the 
button  within  the  gut.  This  running  stitch,  or  purse-string,  is  ap- 
plied in  overhand  fashion,  is  of  catgut  or  silk,  and  carried  upon  two 
long  straight  needles,  one  at  each  end.  Tins  stitch  should  include 
all  the  layers  of  the  gut,  especially  the  serous  and  the  mucous  mem- 
brane; it  should  not  include  too  wide  a  margin  of  the  gut,  since  the 
amount  of  tissue  which  is  grasped  between  the  flanges,  or  cups,  of  the 
button  may  be  too  bulky  to  allow  exact  coaptation;  a  margin  of 
rather  less  than  one-fourth  inch  is  sufficient.  The  running  stitch 
is  commenced  by  piercing  the  mesentery  close  to  the  surface  of  the 
gut,  and  then,  carrying  the  same  needle  back  over  the  edge  of  the 
mesentery,  it  is  again  thrust  through,  so  that  we  thus  have  a  loop 
around  the  cut  edge  of  the  mesentery  close  to  the  surface  of  the 
gut.  Then,  with  this  same  needle,  the  running  suture  is  applied 
to  the  corresponding  half  of  the  circumference  of  the  cut  edge  of 
the  gut;  each  puncture  of  the  needle  should  be  made  from  within 
the  lumen  of  the  gut,  from  its  mucous  membrane  aspect,  and  the 
punctures  should  be  about  one-third  inch  apart.  When  a  point  is 
reached  directly  opposite  the  mesenteric  border  of  the  gut,  this 
needle  is  discarded;  the  second  needle  is  then  taken  in  hand  and  the 
second  half  of  the  circumference  of  the  gut  treated  in  exactly  the 
same  manner.  In  this  way  the  whole  circumference  of  the  gut  is 
included,  leaving  the  two  free  tails  of  the  suture,  which  emerge  upon 
the  serous  surface  of  the  gut  opposite  its  mesenteric  attachment, 
ready  for  tying. 

The  object  in  catching  the  edge  of  the  mesentery  in  the  loop 
of  the  purse-string  suture  is  to  insure  the  turning  in  of  a  serous 
surface  at  this  point  and  at  the  same  time  to  do  away  with  the 
mesenteric  "dead  space" ;  besides,  it  gives  a  fixed  point  to  the  suture. 
Before  introducing  the  button  the  first  double  loop  of  a  surgeon's 
knot  should  be  taken  with  the  ends  of  the  purse-string. 

One-half  of  the  button,  grasped  with  a  thumb  forceps  by  the 
edge  of  its  tubal  part,  is  now  introduced  into  the  end  of  the  gut, 
turning  the  button  a  little  on  the  side  to  facilitate  its  introduction, 
and  while  it  is  thus  held  the  purse-string  is  tied  around  its  shank, 
leaving  the  flange  within  the  intestine.  The  ends  of  the  purse- 
string  are  cut  short  so  that  they  will  not  protrude  between  the 


304 


ABDOMEN  AND  BACK. 


flanges  of  the  button  when  this  is  closed.  This  procedure  is  repeated 
upon  the  other  segment  of  gut.  The  two  halves  of  the  button  are 
then  deliberately  pressed  home,  and  in  doing  this  one  should  note 
that  the  corresponding  mesenteric  attachments  of  both  segments  of 
the  gut  are  opposite  each  other. 


Fig.  135.— End-to-End  Anastomosis  (Murphy  Button). 
With  the  purse-string  suture  a  loop  is  taken  through 
the  layers  of  the  mesentery,  close  to  the  wall  of  the 
gut,  in  order  to  obliterate  the  "dead  space." 


Fig.  136.— Murphy  But- 
ton, the  Two  Halves 
Separated. 


When  the  two  halves  of  the  button  are  locked  there  should  be 
presented  between  them  a  clean,  smooth  line  with  no  raw  mucous 
membrane  edge  protruding,  and  at  the  mesenteric  attachment  the 
apposition  of  serous  surfaces  should  also  be  assured.  Should  there  be 
any  protruding  edge  of  mucous  membrane  between  the  flanges  of  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  305 

button  after  this  has  been  locked,  it  may  be  seized  with  a  thumb 
forceps  and  trimmed  off  short  with  the  scissors.  Any  doubtful  points 
should  be  made  secure  by  adding  several  Lembert  sutures. 

Although  it  is  probably  not  necessary  in  most  cases  to  use  a  layer 
of  Lembert  sutures  in  addition  to  the  Murphy  button  to  secure  ac- 
curate apposition,  nevertheless  it  is  wise  in  many  cases  to  place  a 
continuous  Lembert  stitch  outside  of  the  button  after  the  halves 
have  been  pressed  home,  especially  as  the  presence  of  the  button 
makes  the  application  of  this  stitch  rather  an  easy  matter. 

After  the  hole  in  the  mesentery  has  been  sutured  with  several 
catgut  stitches  as  described  in  the  preceding  operation  the  abdominal 
wound  is  closed. 

The  Murphy  button  causes  a  pressure  atrophy  of  the  edges  of 
the  gut  which  are  caught  between  its  flanges.  When  this  atrophy 
is  complete,  the  button  is  liberated,  taking  the  atrophied  ring  of 
tissue  with  it,  and  thus  an  opening  is  left,  at  the  site  of  the  anas- 
tomosis, which  coresponds  in  size  to  the  full  diameter  of  the  flanges 
of  the  button. 

With  Laplace  Anastomosis  Fokceps. — The  Laplace  anasto- 
mosis forceps  resembles  two  pair  of  haemostatic  forceps,  the  blades 
of  each  being  bent  to  form  half  a  ring.  When  the  two  forceps  are 
united  side  by  side,  their  blades  together  form  a  complete  ring.  The 
two  parts  of  the  instrument  when  joined  are  held  securely  together 
by  means  of  a  clamp  that  is  applied  at  the  rivet.  When  clamped 
the  two  halves  of  the  forceps  work  in  harmony,  and  may  be  opened 
and  closed  like  a  single  instrument.  The  handles  are  provided  with 
a  ratchet,  like  an  ordinary  haemostatic  forceps,  so  that  when  the 
blades  are  closed  they  remain  locked.  The  instruments  are  supplied 
in  five  sizes.  The  McLean  anastomosis  forceps  is  a  modification  of 
the  Laplace  instrument,  and  is  more  simple  in  its  construction. 

After  the  diseased  portion  of  the  gut  has  been  resected  the  ends 
of  the  bowel  are  united  to  each  other  fairly  close  with  four  pene- 
trating sutures  of  catgut  placed  equidistant  apart,  taking  care,  at  the. 
same  time,  that  the  mesenteric  portions  of  both  segments  are  placed 
opposite  each  other.  Of  these  four  sutures  the  one  that  joins  the 
edges  of  the  gut  at  the  mesenteric  border  must  be  introduced  in  such 
a  way  that  when  tied  it  will  obliterate  the  mesenteric  "dead  space." 
This  is  accomplished  by  piercing  the  edge  of  the  gut  close  to  the 
one  layer  of  the  mesentery  and  then  catching  the  other  layer  of  the 
mesentery  at  a  point  some  little  distance  away  from  the  surface  of 


306 


ABDOMEX  AXD  BACK. 


Fig.  137. — Laplace  Anastomosis  Forceps  Separated  into  its  Component  Parts. 


Fig.  138.— Laplace  Anastomosis  Forceps  Joined  Together,   its  Blades  Slightly 
Open.    B,  ring  blades;    C,  clamp;    H,  handle;    8,  shank. 


Fig.  139.— Laplace  Anastomosis  Forceps  Joined  Together,   its  Blades  Closed. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  307 

the  gut — so  that  when  the  suture  is  drawn  tight  it  will  pull  the 
serous  layer  down  into  close  contact  with  the  muscular  coat  of 
the  gut  and  thus  obliterate  the  so-called  "dead  space"  (see  Figs. 
126  and  127).  This  procedure  insures  a  proper  inversion  of  the 
serous  coat  at  the  mesenteric  border — an  essential  to  quick  union 
between  the  edges  of  the  gut.  The  ring-blades  of  the  closed  anasto- 
mosis forceps  are  introduced  between  any  two  of  the  four  sutures 
except  those  upon  either  side  of  the  mesenteric  border.  The  forceps 
is  then  opened — i.e.,  the  blades  spread  apart  so  that  one  ring-blade 
passes  into  each  end  of  the  gut.  In  order  to  facilitate  the  turning 
in,  inversion,  of  the  edges  of  the  gut  so  that  they  may  be  grasped  all 
around  by  the  blades  of  the  forceps  when  they  are  closed,  a  strand  of 
catgut  may  be  thrown  around  the  four  stitches  that  unite  the  edges 
of  the  gut  so  as  to  encircle  them.  By  tightening  this  thread  the 
edges  of  both  segments  of  the  gut  are  turned  inward  toward  the  axis 
of  the  intestine,  in  such  a  manner  that  when  the  ring-blades  of  the 
forceps  are  closed  they  grasp  the  margin  of  each  segment  of  the  gut 
all  around,  serous  surface  to  serous  surface.  The  margin  of  each 
segment,  for  its  entire  circumference,  should  be  grasped  between  the 
closed  ring-blades  of  the  forceps.  The  ends  of  the  strand  of  catgut 
are  then  cut  short. 

The  two  ends  of  the  gut  are  united  to  each  other,  all  around  the 
circumference  of  the  ring-blades  of  the  forceps,  with  a  continuous, 
non-penetrating  Lembert  suture  of  silk  except  at  the  point  where 
the  shank  of  the  forceps  emerges.  After  this  suture  has  been  ap- 
plied the  clamp  is  removed  from  the  forceps,  which  then  separates 
into  its  two  component  parts;  the  blades  of  each  portion  represent 
but  half  a  ring,  and  these  are  withdrawn  from  within  the  intestine, 
one  at  a  time.  The  small  opening  through  which  the  two  parts  of 
the  forceps  were  removed  is  closed  with  one  or  two  additional  Lem- 
bert sutures.  If  desired,  a  second  outside  row  of  Lembert  sutures 
may  be  applied  to  still  further  secure  the  union  of  the  two  ends  of 
gut. 

With  O'Hara  Anastomosis  Forceps. — O'Hara's  anastomosis 
forceps  is  composed  practically  of  two  long,  thin-bladed  haemostatic 
forceps  that  may  be  joined  securely  to  each  other,  side  by  side,  with 
a  clamp.  When  thus  joined  together  both  forceps  work  in  harmony 
as  one  single  instrument.  The  handles  of  the  instrument  are  pro- 
vided with  a  ratchet  arrangement  like  ordinary  artery  forceps,  so 
that  when  the  blades  are  closed  they  remain  locked  until  released. 


308 


ABDOMEN  AND  BACK. 


Fig.  140.— O'Hara  Anastomosis  Forceps  Separated  into  its  Component  Parts. 


Fig.  141.— O'Hara  Anastomosis  Forceps  Joined  Together,  its  Blades  Open. 


Fig.   142.— O'Hara  Anastomosis  Forceps  Joined   Together,   its   Blades  Closed. 


Fig.   143.— End-to-End  Anastomosis  with  the.  O'Hara   Anastomosis  Forceps. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  309 

The  blades  are  serrated,  so  that  the  parts  within  their  grasp  cannot 
escape,  and  they  are  also  graduated  with  file-marks,  so  that  the 
length  of  tissue  grasped  between  them  may  be  accurately  estimated. 

The  coil  of  gut  that  is  to  be  resected  is  brought  out  through  the 
incision  in  the  abdomen  and  the  corresponding  portion  of  the  mesen- 
tery is  tied  off.  One  O'Hara  forceps  is  then  applied  to  the  gut  below 
the  seat  of  disease  and  locked,  and  the  other  forceps  secures  the 
intestine  above  the  seat  of  disease  and  is  likewise  locked.  Each  for- 
ceps grasps  the  gut  at  right  angles  to  its  long  axis.  The  tip  of  each 
forceps,  as  it  grasps  the  intestine,  should  reach  just  to,  or  a  trifle 
short  of,  the  mesenteric  border.  The  diseased  segment  of  gut  is 
then  excised  with  long,  straight  scissors  in  the  usual  way,  cutting 
fairly  close  to  the  blades  of  each  O'Hara  forceps.  Before  severing 
the  gut  ordinary  compression  clamps  may  be  applied  to  it — one  imme- 
diately above  and  another  immediately  below  the  diseased  portion 
that  is  to  be  removed;  so  that  when  the  gut  is  divided  there  will  not 
be  any  escape  of  intestinal  contents.  The  mesentery  corresponding 
to  the  diseased  segment  of  gut  may  be  tied  off  before  or  after  the 
gut  has  been  severed.  The  two  O'Hara  forceps  are  then  approxi- 
mated and  fixed  securely  together  side  by  side  with  the  clamp. 

Commencing  near  the  rivet  and  working  toward  the  tip  of  the 
forceps,  the  two  segments  of  gut  are  united  with  a  continuous,  non- 
penetrating Lembert  suture.  This  suture  catches  the  wall  of  each 
segment  of  gut  just  beyond  the  blades  of  the  forceps;  so  that  the 
forceps  are  thus  gradually  buried,  being  invaginated  into  the  lumen  of 
the  gut  as  the  suture  progresses.  When  the  tips  of  the  conjoined  for- 
ceps are  reached,  the  gut  and  forceps  are  turned  over,  so  as  to  gain 
access  to  the  other  aspect  of  the  gut,  and  the  suture  is  continued 
along  this  side  of  the  gut  toward  the  rivet  of  the  forceps  until  the 
point  is  reached  where  the  suture  commenced.  In  working  around 
the  tips  of  the  united  forceps  at  the  mesenteric  border  of  the  gut 
pains  should  be  taken  to  include  the  serous  coat  in  the  suture.  The 
clamp  is  now  removed,  thus  separating  the  two  forceps.  First  one 
forceps  is  unlocked  and  withdrawn,  then  the  second  is  unlocked  and 
its  blades  passed  up  and  down  across  the  line  of  junction  to  show 
that  this  is  patent  and  that  none  of  the  stitches  have  been  carried 
across  the  lumen  of  the  gut  so  as  to  include  the  opposite  wall,  and 
then  this  is  likewise  withdrawn.  The  small  opening  that  is  left  in 
the  line  of  junction  after  the  forceps- have  been  withdrawn  is  closed 
with  one  or  two  additional  Lembert  sutures. 


310  ABDOMEN  AND  BACK. 

Side-to-Side,  or  Lateral,  Approximation  (Lateral  Intestinal  Anas- 
tomosis).— This  is  the  formation  of  a  fistulous  opening  between  two 
coils  of  intestine  joined  side  to  side. 

This  operation  is  indicated  when  the  ends  of  gut  that  are  to  be 
united  differ  much  in  caliber, — for  example,  to  unite  the  end  of  the 
ileum  to  the  caecum, — or  where  the  intestinal  tube  is  very  narrow, 
as,  for  example,  in  children.  It  may  be  accomplished  by  suture, 
Murphy  button,  or  McGraw  rubber  suture,  etc. 

Suture. — The  intestine  is  brought  well  up  into  the  wound  or,  if 
possible,  outside  upon  the  abdomen,  and  surrounded  with  gauze  pads 
to  protect  the  peritoneal  cavity.  Gauze  strips  are  tied  around  the 
intestine,  and  after  the  diseased  portion  has  been  excised  the  cut  end 
of  each  segment  of  the  gut  is  inverted  and  closed  with  a  double  row  of 
Lembert  sutures,  thus  converting  each  end  of  the  gut  into  a  blind 
pouch.  Care  should  be  taken  to  include  the  invaginated  mesentery 
in  the  suture.  The  invagination  of  the  end  of  the  gut  is  commenced 
at  its  mesenteric  border,  inverting  a  margin  about  one  inch  in  width. 

The  next  step  is  the  union  of  the  two  blind  ends  of  the  gut  to 
each  other,  side  to  side,  and  in  such  a  manner  that  the  intestinal 
canal,  through  the  new  opening  that  is  to  be  made,  will  be  continued 
in  a  direct  line,  and  not  reversed  in  passing  from  one  segment  into 
the  other.  The  ends  of  the  gut  should  be  so  placed  that  they  over- 
lap each  other  for  a  distance  of  four  to  five  inches;  their  apposed 
lateral  surfaces  are  then  united  to  each  other,  for  a  distance  of  from 
three  to  four  inches,  by  a  single  row  of  continuous  Lembert  sutures 
of  fine  silk.  That  segment  of  gut  which  overlaps  the  other  segment  is 
turned  over  upon  its  side  while  the  suture  is  being  applied  so  that 
the  completed  operation  will  show  the  two  coils  of  gut  joined  to- 
gether by  their  lateral  surfaces.  After  this  row  of  Lembert  suture, 
which  forms  the  posterior  half  of  the  "outside. serous  ring,"  has  been 
applied,  the  needle,  still  carrying  the  fine  silk,  is  laid  aside  until 
required  later  to  complete  this  "outside  serous  ring."  This  line  of 
Lembert  sutures  should  be  one  inch  longer  than  the  proposed  open- 
ings in  the  gut,  and  each  stitch  should  be  rather  less  than  one- 
eighth  inch  distant  from  its  neighbor  and  should  be  drawn  tight. 

Each  segment  of  the  bowel  is  now  opened  with  the  scissors,  the 
incisions  being  placed  about  one-fourth  inch  distant  from  the  line 
of  the  Lembert  suture;  the  openings  in  the  bowel  should  be  large 
so  as  to  allow  for  subsequent  contraction, — three  inches  long  and 
at  least  one  inch  shorter  than  the  line  of  the  Lembert  suture. 


Fig.  144. — Lateral  Anastomosis.  The  end  of  each  coil  of  gut  has  been 
closed  by  suture.  The  two  coils  have  been  placed  side  by  side  and  joined 
by  a  continuous  non-penetrating  suture.  An  opening  has  been  made  in  each 
coil  of  gut. 


145. —  Lateral    Anastomosis    with    Murphy    Button.      A    purse-string 
been  introduced  in  both  segments.     One  segment  has  been  incised. 


has 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  31 1 

Bleeding  from  the  edges  of  the  incisions  in  the  bowel  is  con- 
trolled with  clamps,  which  may  be  removed  after  a  few  minutes' 
pressure,  as  the  hemorrhage  usually  ceases.  The  edges  of  the  open- 
ings in  the  gut  are  wiped  with  alcohol  followed  by  a  weak  bichloride 
solution,  and  then,  with  a  continuous  catgut  or  silk  suture,  which  at 
the  same  time  controls  the  hemorrhage,  the  edges  of  the  opening 
in  each  segment  of  the  bowel  are  united  with  each  other  all  around. 
Having  thus  united  the  edges  of  the  openings  all  around,  we  again 
take  up  the  needle  carrying  the  original  silk  suture  and  complete 
the  anastomosis  by  making  the  anterior  half  of  the  Lembert  suture, 
the  "outside  serous  ring."  The  line  of  Lembert  suture  serves  to  bury 
the  suture  by  which  the  margins  of  the  openings  in  the  gut  are  joined 
to  each  other. 

In  making  the  lateral  anastomosis  one  should  not  have  the  blind 
ends  of  the  overlapped  gut  too  long.  These  ends  should  be  anchored 
to  the  adjoining  wall  of  the  intestine  by  several  Lembert  stitches. 

It  may  be  necessary  to  tear  the  mesentery  somewhat  in  order 
to  allow  sufficient  overlapping  of  the  ends  of  the  bowel.  After  the 
anastomosis  has  been  made  the  overlapping  layers  of  the  mesentery 
may  be  united  with  a  continuous  catgut  stitch.  The  parts  are  then 
returned  to  the  abdomen  and  the  wound  closed  up. 

With  Mukpht  Button. — A  lateral  intestinal  anastomosis  may 
be  made  with  the  Murphy  button.  After  the  ends  of  the  gut  have 
been  inverted  and  closed  with  a  suture  as  described  in  the  preceding 
operation,  the  two  ends  are  placed  side  by  side  and  a  purse-string 
placed  in  the  lateral  wall  of  each  segment.  The  purse-string  consists 
of  two  parallel  rows  with  a  space  between  them  of  not  more  than 
one-half  inch  so  that  when  the  incision  is  made  there  will  be  a  mar- 
gin on  each  side  of  about  one-fourth  inch.  Each  leg  of  the  suture 
should  be  made  with  three  punctures  of  the  needle,  penetrating  the 
entire  thickness  of  the  bowel  with  each  thrust.  Either  silk  or  plain 
catgut  may  be  used  as  suture  material.  The  writer  prefers  catgut. 
The  first  double  loop  of  a  surgeon's  knot  is  taken  with  the  ends  of 
the  suture  and  the  incision  in  the  bowel  then  made.  The  incision 
should  not  be  too  large — barely  large  enough  to  permit  introduction 
of  the  half  button  and  should  be  placed  exactly  between  the  two 
legs  of  the  suture.  The  incision  in  the  bowel  is  made  with  the 
scissors,  the  wall  of  the  gut  being  picked  up  with  two  thumb  forceps 
to  facilitate  this  step.  The  two  halves  of  the  button  are  introduced, 
one  into  each  loop  of  the  gut,  pressed  together,  and  the  operation 


312  ABDOMEN"  AND  BACK. 

thus  completed.  This  is  a  very  convenient  and  simple  method  of 
doing  a  primary  lateral  intestinal  anastomosis,  but  the  result  may 
he  disappointing  because  the  opening  left  by  the  Murphy  button 
is  at  times  too  small  to  allow  for  the  subsequent  contraction  that 
always  takes  place.  The  comparative  simplicity  and  speed  with 
which  the  anastomosis  may  be  established  with  the  button,  however, 
make  it  of  especial  value  to  the  inexperienced  in  emergencies  and 
\7l1ere  time  presses.  The  Murphy  button  is  also  commonly  employed 
to  make  the  lateral  entero-anastomosis  in  connection  with  gastro- 
jejunostomy. 

With  McGraw's  Eubber  Suture. — With  the  rubber  suture  a 
lateral  intestinal  anastomosis  may  be  conveniently  made,  and  with 
very  good  result,  in  a  manner  analogous  to  that  described  for  the 
gastrojejunostomy.  The  surfaces  of  the  two  segments  of  gut  that 
are  to  be  joined  are  placed  side  by  side  and  united  for  a  distance  of 
about  two  and  one-half  inches  with  a  continuous  Lembert  stitch  of 
silk  as  described  in  the  previous  operation,  and  then  the  needle 
carrying  this  stitch  is  temporarily  laid  aside.  The  rubber  suture,  2  to 
3  mm.  thick,  is  introduced  with  a  straight  needle,  so  as  to  include 
both  segments  of  the  gut  in  its  grasp,  is  drawn  tight,  and  tied.  A 
silk  ligature  is  tied  around  the  knot  in  the  rubber  suture  so  as  to 
secure  the  latter  from  slipping.  About  two  inches  of  the  length  of 
each  segment  of  the  gut  should  be  included  in  the  constricting  rubber 
suture ;  so  that,  when  this  cuts  through,  the  opening  left  between  the 
two  coils  of  gut  will  be  two  inches  in  length  (see  "Gastrojejunostomy 
with  McGraw's  Eubber  Suture").  The  needle,  still  carrying  the  silk 
thread  and  which  was  temporarily  laid  aside,  is  again  taken  up,  and 
with  this  the  two  coils  of  gut  are  united  along  a  line  just  in  front 
of  the  rubber  suture.  This  forms  the  second,  the  anterior  half  of  the 
"outside  serous  ring"  suture,  and  buries  the  rubber  suture  beneath  it 
out  of  sight. 

With  Laplace  Forceps. — Lateral  anastomosis  with  Laplace 
forceps  is  accomplished  in  a  manner  analogous  to  that  described  for 
gastrojejunostomy. 

With  O'Hara  Anastomosis  Forceps.  —  Lateral  anastomosis 
with  the  O'Hara  forceps  is  done  in  a  manner  similar  to  that  described 
for  gastrojejunostomy. 

Gastroenterostomy. — Gastroenterostomy  is  the  formation  of  a 
fistulous  communication  between  the  stomach  and  the  small  intes- 
tine.   The  anastomosis  may  be  made  between  the  stomach  and  duo- 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  313 

denum  (gastro-duodenostomy)  or  between  the  stomach  and  jejunum 
(gastrojejunostomy). 

The  operation  has  for  its  prime  object  the  establishment  of  a 
sufficiently  free  exit  for  the  escape  of  the  stomach  contents;  for 
stenosis  of  the  pylorus  whether  simple  and  due  to  non-malignant 
chronic  ulcer  or  the  result  of  malignant  disease ;  for  hour-glass  cica- 
tricial contraction  of  the  stomach;  for  the  relief  of  symptoms  of 
chronic  ulcer  and  chronic  gastritis;  dilatation  consecutive  to  pyloric 
stenosis,  etc.;  gastrojejunostomy  is  performed  for  chronic  ulcer  of 
the  duodenum  with  the  object  of  diverting  the  acid  stomach  contents 
from  this  portion  of  the  bowel. 

Gastro-duodenostomy. — The  anastomosis  is  made  between  the 
stomach  and  duodenum.  This  operation  is  illustrated  in  the  method 
of  implanting  the  end  of  the  stump  of  the  duodenum  into  the  poste- 
rior wall  of  the  stomach  after  resection  of  the  pylorus,  etc.,  and  in 
the  operation  of  Finney,  described  as  "P}doroplasty,"  but  which  is 
in  reality  a  gastro-duodenostomy,  the  communication  being  made  be- 
tween the  first  part  of  the  duodenum  and  the  adjacent  portion  of  the 
stomach. 

Gastrojejunostomy. — The  junction  is  made  between  the  stomach 
and  jejunum.  This  operation  was  first  performed  by  Woelfler  in 
1881.  The  loop  of  small  intestine  may  be  fixed  to  either  the  anterior 
or  the  posterior  wall  of  the  stomach. 

Anterior  Gastrojejunostomy  (Woelfler). — This  consists  in 
bringing  a  coil  of  the  small  intestine — jejunum — up  in  front  of  the 
great  omentum  and  transverse  colon  and  fixing  it  to  the  anterior 
wall  of  the  stomach.  Some  surgeons  of  large  experience  prefer  this 
anterior  to  the  posterior  operation.  It  is  certainly  easier  of  execution 
and  the  results  are  good. 

The  stomach  should  be  emptied  and  washed  out  with  the  stom- 
ach tube,  while  the  patient  is  anaesthetized,  immediately  before  the 
operation. 

An  incision  is  made  in  the  middle  line  through  the  linea  alba 
from  a  point  one  inch  below  the  ensiform  cartilage  down  to  the 
umbilicus,  or  even  beyond  this  point  if  necessary.  The  incision  is 
usually  from  four  to  five  inches  long  (10  to  15  cm.). 

Through  this  opening  the  stomach  is  sought  and  examined.  A 
portion  of  the  wall  of  the  stomach  which  is  not  diseased  should  be 
selected.  The  stomach  is  partly  covered  by  the  liver,  the  anterior 
thin  edge  of  the  left  lobe  of  this  organ  being  a  good  guide  to  tha 


314 


ABDOMEN  AND  BACK. 


stomach.  Lying  below  and  close  to  the  greater  curvature  of  the 
stomach  is  the  transverse  colon,  and  from  this  the  great  omentum, 
apron-like,  is  suspended,  hanging  down  free  in  the  abdominal  cavity 
in  front  of  the  small  intestine. 

After  the  stomach  has  been  recognized  the  transverse  colon,  and 
with  it  the  great  omentum,  are  drawn  upward  out  of  the  wound, 
and  search  is  then  made  for  the  commencement  of  the  jejunum. 


Fig.  146.— Gastro-jejunostomy.  The  jejunum  has  been  fixed  to  the  stom- 
ach and  an  opening  made  between  them.  Arrows  (1,  1)  show  the  proper 
course  of  the  stomach  contents  into  the  long  arm  of  the  gut.  Arrows  (2,  2) 
show  the  course  of  stomach  contents  into  the  short  arm  of  the  gut,  through 
which  they  may  again  enter  the  stomach,   "vicious  circle." 

This  part  of  the  gut  lies  in  the  back  of  the  abdominal  cavity,  to  the 
left  of  the  vertebral  column,  upon  a  level  with  the  body  of  the  second 
lumbar  vertebra,  its  mesentery  being  very  short  and  serving  to  anchor 
it  in  this  position.  To  secure  this  coil  of  gut  the  hand  is  introduced 
into  the  abdomen  and  carried  backward,  along  the  under  surface  of 
the  transverse  mesocolon,  as  far  as  the  posterior  abdominal  wall; 
just  below  the  attachment  of  the  transverse  mesocolon  to  the  vertebral 
column,  at  the  place  indicated  upon  the  left  of  the  column,  this  coil 
of  gut  is  found.    This  part  of  the  small  intestine  is  readily  identified 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  315 

"by  the  fact  th'at  it  is  fixed  within,  as  is  demonstrated  when  an  effort 
is  made  to  draw  it  out  of  the  abdomen ;  any  other  part  of  the  small 
intestine  may  be  drawn  through  the  fingers  in  either  direction,  and 
may  be  readily  drawn  out  upon  the  abdomen. 

We  select  a  loop  of  gut  for  attachment  to  the  stomach  about 
eighteen  inches  distant  from  this  fixed  part  of  the  jejunum.  A  loop 
of  gut  about  ten  inches  long  is  drawn  out  upon  the  abdominal  wall 
and  surrounded,  for  the  purpose  of  constricting  its  lumen,  by  two 
thin  strips  of  sterile  gauze.  These  strips  are  carried  around  the  gut 
with  a  sharp-nosed  artery  forceps,  which  is  thrust  through  the  mesen- 
tery close  to  its  attachment  to  the  intestine,  and  with  this  the  end 
of  each  gauze  strip  is  seized  and  drawn  through.  The  one  gauze 
strip  is  tied  and  the  segment  of  gut  emptied  of  its  contents,  to  a 
point  beyond  the  second  piece  of  gauze,  by  "gently  stripping  it  be- 
tween the  fingers,  and  then  the  second  gauze  strip  is  tied.  The 
gauze  strips  should  be  tied  sufficiently  tight  to  prevent  the  re- 
entrance  of  the  intestinal  contents  into  this  segment  of  the  gut. 
The  transverse  colon  and  great  omentum  are  now  pushed  back  into 
the  abdomen  again,  and  the  anterior  surface  of  the  stomach  seized 
and  drawn  out  of  the  abdomen.  Dry,  sterile,  gauze  pads  are  placed 
about  the  stomach  and  intestine  and  tucked  partly  into  the  in- 
cision for  the  purpose  of  retaining  the  parts  outside  of  the  ab- 
domen and  to  prevent  the  entrance  of  escaping  intestinal  contents 
into  the  peritoneal  cavity.  From  now  on  the  operation  is  done 
extraperitoneally. 

The  coil  of  intestine  and  the  stomach  are  steadied,  side  by  side, 
and  united  by  a  continuous  Lembert  suture  of  fine  silk,  using  a 
straight  cambric  needle.  This  suture  line,  which  includes  the  serous 
and  muscular  coats,  forms  the  posterior  half  of  the  "outside  serous 
ring."  It  should  not  penetrate  into  the  cavity  of  the  stomach  or 
intestine.  The  suture  should  be  applied  in  a  straight  line,  about 
two  and  one-half  to  three  inches  long,  each  puncture  of  the  needle 
being  about  one-eighth  inch  distant  from  its  neighbor,  and  should 
take  a  good,  broad  bite.  Each  stitch  should  be  drawn  fairly  tight.  It 
is  probably  more  convenient  for  the  operator,  in  applying  this  suture, 
to  commence  at  the  far  end  and  sew  toward  himself,  steadying  the 
parts  with  the  thumb  and  index  finger  of  left  hand.  The  tail  of  the 
suture  should  be  left  long,  and  may  be  held  by  the  assistant  as  a 
tractor.  After  this  line  of  suture  has  been  completed,  the  needle, 
carrying  this  thread,  is  laid  aside  until  needed  later  to  complete  the 


316  ABDOMEN  AND  BACK. 

operation  by  making  the  anterior  half  of  the  "outside  serous  ring" 
suture. 

The  openings  in  the  intestine  and  stomach  are  next  made. 
These  incisions  should  be  one  and  one-half  to  two  inches  long.  They 
should  be  shorter  than  the  line  of  the  Lembert  suture,  and  should 
be  placed  about  one-fourth  inch  distant  from  it.  They  should  be 
straight,  parallel  with  the  line  of  suture,  and  clean  cut.  The  intes- 
tine should  be  incised  first.  The  wall  of  the  gut  is  picked  up  with 
two  toothed  forceps  and  a  small  opening  made  between  these  with  a 
straight,  sharp  scissors  and  then  the  opening  thus  made  is  sufficiently 
enlarged.  Any  escaping  contents  are  carefully  swabbed  away  with 
gauze  wipes.  The  stomach  is  treated  in  a  similar  manner.  Hemor- 
rhage from  the  edges  of  these  incisions  stops  after  they  have  been 
sutured;  any  spurting  points  may  be  clamped  and  tied  with  fine  silk 
or  catgut. 

The  adjoining  edges  of  the  incisions  in  the  intestine  and  stom- 
ach are  sewed  to  each  other  with  catgut  in  a  medium-sized,  straight 
needle,  each  stitch  taking  a  good  bite  and  passing  through  all  the 
coats,  including  the  mucous  membrane,  and  drawn  fairly  tight:  the 
needle  punctures  should  be  rather  less  than  one-fourth  inch  apart. 
This  suture  is  continued  uninterrupted  all  around,  uniting  the  cor- 
responding edges  of  the  incisions  in  the  stomach  and  intestine  to 
each  other  until  these  openings  are  entirely  closed  in  and  the  anasto- 
mosis made.  Before  beginning  this  stitch  the  margins  of  the  open- 
ings should  be  wiped  off  with  alcohol  followed  by  a  weak  bichloride 
solution  on  a  swab. 

"We  now  again  take  up  the  needle  with  which  the  posterior  half 
of  the  Lembert  suture — "outside  serous  ring" — was  made,  and  com- 
plete the  operation  by  making  the  anterior  half  of  the  "outside 
serous  ring"  suture. 

Thus  we  have  the  openings  in  the  intestine  and  stomach,  one 
and  one-half  to  two  inches  long,  united,  edge  to  edge,  by  a  con- 
tinuous stitch  which  passes  through  the  entire  thickness  of  the  mar- 
gins of  the  contiguous  openings,  and  this  surrounded,  reinforced, 
by  a  continuous  Lembert  suture  which  passes  through  the  serous 
and  muscular  coats  only  and  which  serves  the  purpose  of  burying  the 
penetrating  mucous  stitch.  Should  there  be  any  doubtful  points 
where  the  mucous  penetrating  stitch  is  not  certainly  buried,  one  or 
more  supplementary  interrupted  Lembert  stitches  may  be  taken  to 
remedy  this. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  317 

The  coil  of  intestine  should  be  joined  to  the  stomach  low  down, 
close  to  its  greater  curvature  and  about  three  inches  from  its  pyloric 
opening-  The  incision  in  the  intestine  should  be  made  opposite  its 
mesenteric  attachment.  The  intestine  should  be  joined  to  the  stom- 
ach in  such  a  way  that  the  current  of  food  in  the  stomach  and  in  the 
loop  of  intestine  will  be  in  the  same  direction — the  distal  limb  of  the 
loop  of  gut  toward  the  right  or  pyloric  end  of  the  stomach;  this  is 
accomplished  by  taking  care  not  to  twist  the  loop  of  intestine  upon 
itself  when  drawing  it  up  into  apposition  with  the  stomach. 

The  transverse  colon  and  great  omentum  rolled  upon  itself 
lie  together  behind  the  junction  formed  between  the  jejunum  and 
the  stomach. 

The  constricting  tapes  are  finally  removed  from  the  intestine 
and  the  parts  replaced  within  the  abdomen. 

The  opening  in  the  abdomen  is  closed  with  several  silk-worm 
gut  sutures,  which  pass  through  the  whole  thickness  of  the  abdominal 
wall,  care  being  taken  to  include  the  edges  of  the  parietal  perito- 
neum. These  stitches  should  be  about  one-half  inch  apart.  It  is 
probably  better  to  suture  the  edges  of  the  peritoneum  first  with  a 
continuous  catgut  stitch  and  after  this  the  silk-worm  stitches  are 
applied  so  as  to  include  the  other  layers  of  the  abdominal  wall. 

Posterior  Gastrojejunostomy  (von  Hacker). — The  jejunum 
is  sutured  to  the  posterior  wall  of  the  stomach,  which  is  exposed 
through  an  opening  torn  in  the  transverse  mesocolon. 

This  operation  is  preferred  by  some  surgeons  to  the  anterior. 
The  position  of  the  parts  is  said  to  be  more  natural  and  the  trans- 
verse colon  is  not  displaced,  and  cannot,  therefore,  drag  upon  the 
coil  of  jejunum  that  is  fixed  to  the  stomach.  The  technique  of  this 
operation  for  the  less  experienced  operator  is  rather  more  difficult 
than  that  of  the  anterior;  the  choice  between  the  anterior  and  poste- 
rior operation  will  probably  depend,  in  most  cases,  upon  the  location 
of  the  disease. 

An  incision  is  made  in  the  middle  line  through  the  linea  alba, 
as  in  the  preceding  operation.  The  stomach  is  recognized  and  ex- 
amined. The  transverse  colon  and  greater  omentum  are  then  re- 
flected upward  and  the  stomach  drawn  out  of  the  incision  in  the 
abdomen.  An  opening  is  cut,  or  better  torn,  in  the  transverse  meso- 
colon, penetrating  from  its  inferior  aspect,  in  order  to  expose  a  suffi- 
cient area  of  the  posterior  wall  of  the  stomach.  Care  must  be  exer- 
cised not  to  injure  any  blood-vessels  in  making  this  opening  in  the 


318  ABDOMEN  AND  BACK. 

transverse  mesocolon,  particularly  the  arteria  colica  media.  The 
posterior  wall  of  the  stomach  is  drawn  partly  through  the  opening 
which  is  thus  made  in  the  transverse  mesocolon,  the  edges  of  the 
opening  in  the  mesocolon  being  fixed  at  once  to  the  posterior  wall  of 
the  stomach  by  several  fine  silk  sutures  (which  do  not,  of  course, 
pierce  the  entire  thickness  of  the  stomach  wall).    The  exposed  area 


Fig.  147. — Gastro-jejunostomy  (Jaboulay-Braun).  Compare  with  Fig.  146 
Lateral  anastomosis  has  been  made  between  the  arms  of  the  attached  loop  of 
gut;  so  that  if  the  stomach  contents  do  enter  the  short  arm  of  the  gut  (2,  2) 
they  may  still  escape  into  the  proper  long  arm.  This  measure  prevents  the 
occurrence   of  the   "vicious   circle." 

of  the  stomach  is  then  brought  up  into  the  incision  in  the  abdomen 
and  out  upon  the  abdominal  wall,  where  it  is  retained  by  an  assistant. 
As  in  the  preceding  operation,  the  commencement  of  the  jeju- 
num is  sought  for  and  found  in  the  back  of  the  abdomen  to  the  left 
of  the  body  of  the  second  lumbar  vertebra,  just  below  the  vertebral 
attachment  of  the  transverse  mesocolon.  A  coil  of  intestine  about 
twelve  inches   away  from  the   commencement   of   the  jejunum  is 


Fig.  14S. — Posterior  Gastrojejunostomy.  Great  omentum  and  transverse 
colon  have  been  drawn  out  of  the  incision  and  turned  upward.  An  opening 
has  been  made  in  the  transverse  mesocolon  in  order  to  expose  a  portion  of 
the  posterior  wall  of  the  stomach.  A  loop  of  jejunum  has  been  fixed  to  the 
wall  of  the  stomach  with  a  continuous,  non-penetrating  stitch  and  openings 
made  in  the  stomach  and  the  attached  coil  of  gut.  The  loop  of  gut  has  been 
temporarily  tied  off  with  tapes. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  319 

selected,  and  this  is  also  brought  out  of  the  abdominal  wound  and 
placed  alongside  of  that  portion  of  the  posterior  wall  of  the  stomach 
which  presents  through  the  opening  in  the  transverse  mesocolon. 
Pads  of  gauze  are  tucked  about  the  viscera  and  partly  into  the  ab- 
dominal incision  to  steady  the  parts  and  to  prevent  the  entrance  of 
material  from  the  stomach  or  intestine  into  the  peritoneal  cavity,  and 
the  gastrojejunostomy  is  then  performed  as  in  the  preceding  opera- 
tion. The  intestine  is  fixed  to  the  posterior  wall  of  the  stomach, 
close  to  the  greater  curvature,  and  from  three  to  three  and  one-half 
inches  away  from  the  pylorus.  The  coil  should  be  fixed  so  that  the 
current  of  food  through  the  stomach  and  the  intestines  are  in  the 
same  direction. 

Jaboulay  and  Bkauist  Modification. — In  some  cases,  after  the 
anterior  or  posterior  gastrojejunostomy  as  described  above  has  been 
performed,  there  occurs  an  accumulation  of  food,  bile,  and  pan- 
creatic juice  in  the  short  (proximal)  limb  of  the  loop  of  the  intestine 
that  is  fixed  to  the  stomach,  with  a  consequent  regurgitation  into  the 
stomach,  and  this  is  characterized  by  exhausting  and  fatal  vomiting. 
This  regurgitation  and  vomiting  are  due  to  a  spur  formation  in  the 
attached  coil  of  gut  which  directs  the  stomach  contents  into  the  short 
or  proximal  arm  of  the  gut.  In  order  to  avoid  the  occurrence  of  this 
vomiting — "vicious  circle" — a  lateral  communication  between  the 
two  limbs  of  the  coil  of  intestine  which  has  been  attached  to  the 
stomach  may  be  made,  and  this  may  be  done  either  at  the  same  time 
that  the  gastrojejunostomy  is  performed,  or,  since  this  regurgita- 
tion, etc.,  do  not  occur  in  all  cases,  it  may  be  done  later  as  a  sec- 
ondary operation,  in  this  latter  case  waiting  for  the  appearance  of 
symptoms  indicating  the  necessity  of  the  additional  operation  before 
submitting  the  patient  to  the  additional  risk.  It  is  probably  wise,  in 
most  cases,  to  do  this  entero-anastomosis  at  the  same  time  as  the 
primary  gastrojejunostomy,  as  it  occupies  but  a  few  minutes'  addi- 
tional time.  This  secondary  entero-anastomosis  may  be  made  with 
suture,  Murphy  button,  or  McG-raw's  rubber  suture,  etc.  The  com- 
munication between  the  two  limbs  of  the  loop  of  gut  should  be  made  at 
their  most  dependent  part. 

If  the  Murphy  button  is  used  for  this  purpose  the  two  halves 
of  the  button  may  be  dropped,  one  into  each  limb  of  the  attached 
loop  of  intestine,  through  the  opening  that  is  made  in  it  for  the  pur- 
pose of  anastomosing  it  with  the  stomach.  Each  half  of  the  button 
is  then  seized  through  the  wall  of  the  gut  and  its  tubal  portion 


320  ABDOMEN  AND  BACK. 

pushed  out  through  a  small  incision  that  is  made  in  the  side  of  each 
limb  of  the  attached  loop  of  gut.  The  two  halves  of  the  button  are 
then  forced  together  and  the  anastomosis  thus  accomplished  without 
using  any  sutures  whatever.  ,  For  the  details  of  the  operation  of 
lateral  intestinal  anastomosis  with  the  simple  suture,  McGraw  rub- 
ber ligature,  etc.,  the  reader  is  referred  to  the  description  of  these 
various  procedures  as  they  are  given  elsewhere  in  this  volume. 

Gastrojejunostomy  with  the  Murphy  Button. — This  is  a 
simple  operation,  and  much  time  can  be  saved  by  the  use  of  the 
device.  The  button  can  be  used  to  make  the  anastomosis  no  matter 
which  method  is  employed.  The  "vicious  circle"  phenomena,  re- 
gurgitation, vomiting,  etc.,  are  much  less  frequently  seen  where  the 
Murphy  button  is  used.  This  is  probably  due  to  the  fact  that  the 
solid  button  prevents  "kinking"  of  the  loop  of  gut  where  it  is 
attached  to  the  stomach. 

The  use  of  the  Murphy  button  is  no  doubt  indicated  in  many 
cases,  especially  where  a  malignant  condition  exists  and  the  time 
permitted  for  the  performance  of  the  operation  is  short.  The 
medium-size  button  may  be  used  for  the  gastrojejunostomy,  and  a 
smaller  one  for  the  entero-anastomosis,  if  this  latter  operation  is 
performed  in  addition. 

If  a  posterior  gastrojejunostomy  is  made,  the  button,  when 
liberated,  is  less  likely  to  fall  into  the  stomach  than  when  the  ante- 
rior gastrojejunostomy  is  the  operation  performed.  According  to 
the  suggestion  of  Weir,  the  margin  of  that  half  of  the  button  which 
presents  into  the  intestine  may  be  provided  with  projecting  flanges, 
which  should  hinder  the  button  from  falling  into  the  stomach. 

The  stomach  and  intestine  are  brought  out  upon  the  abdomen 
as  in  the  operations  above  described.  A  running  stitch  is  introduced 
into  the  wall  of  the  intestine  and  the  wall  of  the  stomach,  penetrat- 
ing through  the  entire  thickness  of  the  wall  of  each.  The  space  in- 
cluded between  the  two  limbs  of  this  running,  or  purse-string,  suture 
should  be  about  one-half  inch  (for  description  of  the  running,  purse- 
string  suture  and  the  method  of  its  introduction  see  "Lateral  Intes- 
tinal Anastomosis"  and  "Cholecysto-duodenostomy").  This  purse- 
string  suture  is  applied  first  to  the  jejunum,  and  then  between  the  two 
limbs  of  the  suture  line  an  incision  is  made  into  the  gut;  this  should 
be  barely  large  enough  to  permit  the  introduction  of  the  half  button. 
That  half  button  which  is  provided  with  the  spring  is  seized  with  a 
thumb  forceps  and  introduced  sidewise  through  the  incision  into  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  321 

gut,  and,  while  it  is  thus  steadied,  the  running  string  is  drawn  tight 
about  its  shank,  tied,  and  the  ends  cut  short. 

In  a  similar  manner,  after  the  purse-string  has  been  applied  to 
the  wall  of  the  stomach,  this  is  incised,  and  the  other  half  of  the 
button  is  introduced  into  this  incision  and  the  string  tied  about  its 
neck.  The  parts  adjacent  to  the  openings  are  then  sponged  off  with 
a  wet  bichloride  pad  and  the  two  halves  of  the  button  deliberately 
pressed  home.  They  should  be  applied  sufficiently  tight  to  cause  a 
gradual  pressure  necrosis  of  those  parts  of  the  walls  of  the  viscera 
that  are  included  within  their  grasp.  No  raw  edge  of  mucous  mem- 
brane should  be  seen  protruding  between  the  two  halves  of  the 
button.  If  any  raw  edge  of  mucous  membrane  does  present  itself 
between  the  flanges  of  the  button,  it  should  be  seized  with  the  thumb 
forceps  and  trimmed  close  with  sharp  scissors,  and  then  be  still 
farther  buried  with  several  additional  Lembert  stitches.  Murphy 
claims  that  the  additional  outside  Lembert  stitch  is,  as  a  rule,  un- 
necessary; nevertheless,  it  is  well  to  use  it  if  time  permits,  and 
especially  if  there  are  any  doubtful  points.  The  button  being  in 
position,  the  application  of  the  Lembert  stitch  is  easy.  Spurting 
vessels  in  the  edges  of  the  openings  in  the  intestine  and  stomach  may 
be  clamped  and  tied  with  fine  catgut  or  fine  silk. 

Carle  applies  the  Murphy  button  without  using  the  purse-string. 
A  simple  clean-cut  incision  is  made  in  the  jejunum  and  in  the  stom- 
ach barely  large  enough  to  admit  the  button.  After  the  button  has 
been  introduced  the  incision  is  diminished  by  a  single  Lembert  stitch 
at  each  end  of  the  incision  and  the  two  halves  of  the  button  then 
pressed  home.  It  is  said  to  be  perfectly  safe  and  to  give  more  per- 
fect apposition  than  with  the  purse-string  and  saves  much  time. 
After  the  button  has  been  introduced  and  locked  several  outside 
Lembert  sutures  may  be  introduced,  especially  if  there  are  any 
doubtful  points  and  if  time  permits. 

Gastrojejunostomy  with  McGraw's  Kubber  Suture. — The 
gut  is  brought  into  apposition  with  the  anterior  or  posterior  surface 
of  the  stomach,  as  described  in  the  preceding  operations,  and  these 
two  portions  of  the  alimentary  canal  are  joined  to  each  other  with 
a  continuous  silk  Lembert  stitch  for  a  distance  of  about  two  and 
one-half  inches.  After  this  line  of  suture  has  been  introduced,  the 
needle  still  carrying  the  suture  is  temporarily  laid  aside. 

The  stomach  is  then  united  to  the  intestine  with  a  single  suture 
of  solid  rubber,  smooth  and  round  and  from  2  to  5  mm.  in  thickness. 

21 


322 


ABDOMEN  AND  BACK. 


This  suture  is  carried  in  the  eye  of  a  long  straight  needle;  a  large 
worsted  needle  or  Hagedorn  needle  answers  well  for  this  purpose. 
It  will  be  necessary  to  shave  the  end  of  the  rubber  suture  so  that 
it  may  enter  the  eye  of  the  needle.    The  point  of  the  needle  is  passed 


Fig.  149.—  Gastrojejunostomy  (McOraw).  A  loop  of  intestine  has  been 
fixed  to  the  wall  of  the  stomach  with  a  continuous,  non-penetrating  stitch 
(A,  A).  Rubber  ligature  (B,  B,  B),  which  has  been  passed  through  the  stom- 
ach and  intestine,  ready  for  tying. 

into  the  stomach  and  then  out  again,  so  that  about  two  inches  of  the 
wall  of  the  stomach,  corresponding  to  its  long  diameter,  are  included 
between  the  two  punctures.     The  rubber  suture  is  put  upon  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  323 

stretch  and  the  needle,  pulling  the  suture  after  it,  is  then  drawn 
through.  With  the  same  needle  and  suture,  and  in  a  similar  manner, 
the  intestine  is  pierced,  entering  and  emerging  at  points  opposite 
the  puncture  holes  in  the  stomach. 

The  rubber  suture  is  drawn  very  tight,  thus  constricting  the 
parts  included  in  its  grasp,  and  tied.  In  order  to  secure  the  knot 
in  the  rubber  suture  a  strand  of  stout  silk  may  be  placed  underneath 
the  rubber  at  the  place  where  the  knot  is  to  be,  and  after  one  loop 
of  the  knot  has  been  taken  in  the  rubber  suture  the  silk  ligature  is 
tied  over  it  and  then  the  second,  final  loop  of  the  knot  is  taken  in  the 
rubber  suture  and  the  silk  ligature  again  tied  over  this.  The  ends  of 
both  rubber  and  silk  ligatures  are  cut  very  short. 

In  passing  the  rubber  suture  one  should  make  certain  that  the 
needle  pierces  the  entire  thickness  of  the  wall  of  the  organ  and  that 
it  does  not  pick  up  the  mucous  membrane  of  the  viscus  on  its  way 
to  make  the  second  puncture — that  of  exit;  in  each  viscus  there 
should  be  two  punctures  only, — one  as  the  needle  passes  in  and  one 
as  the  needle  passes  out. 

In  drawing  the  rubber  suture  after  the  needle,  through  the  wall 
of  the  stomach  and  intestine,  it  may  be  stretched  so  that  it  becomes 
thinner,  and  may  thus  the  more  readily  follow  the  needle  through 
the  punctures.  When  the  suture  is  relaxed  it  becomes  increased  in 
diameter  so  that  it  more  than  fills  the  puncture  holes  and  thus  pre- 
vents leakage. 

Finally,  to  complete  the  operation,  the  needle,  carrying  the  silk 
thread  with  which  the  first  half  of  the  Lembert  "outside  serous  ring" 
suture  was  applied,  is  again  taken  in  hand  and  with  it  the  wall  of 
the  stomach  and  intestine  are  joined  with  a  continuous  stitch,  which 
is  applied  along  a  line  just  in  front  of,  anterior  to,  the  rubber  liga- 
ture, and  which  buries  this  latter  and  completes  the  "outside  serous 
ring"  suture. 

By  this  operation  corresponding  portions  of  the  opposed  walls 
of  the  stomach  and  the  intestine  are  included  in  the  grasp  of  a  single, 
elastic  rubber  suture,  which,  when  drawn  very  tight,  gradually  cuts 
its  way  through  the  walls  of  the  united  viscera,  with  the  result  that 
after  the  lapse  of  two  days  the  gastrojejunostomy  is  established  and 
the  liberated  rubber  suture  is  passed  unobserved  through  the  bowel. 
This  plan  of  operation  may  also  be  employed  in  making  a  lateral  anas- 
tomosis between  two  coils  of  the  small  intestine  or  between  the  small 
and  large  intestine. 


324  ABDOMEN  AND  BACK. 

Gastrojejunostomy  with  Laplace  Forceps.  —  After  the 
stomach  and  intestine  have  been  brought  up  into  the  abdominal  in- 
cision an  opening  is  made  in  each  viscus,  which  opening  should  be 
rather  smaller  than  the  ring-blades  of  the  forceps  that  is  to  be  used. 

The  ring-blades  of  the  forceps,  joined  together  and  secured  with 
the  clamp,  are  introduced,  one  into  each  organ,  and  then  closed,  with 
the  result  that  the  margins  of  each  opening  are  securely  grasped  be- 
tween them,  serous  surface  being  apposed  to  serous  surface.  Care 
must  be  exercised  to  include  the  entire  margin  of  each  opening  in 
the  grasp  of  the  closed  blades,  and  this  is  facilitated  by  using  an  in- 
strument whose  ring  is  larger  in  circumference  than  the  correspond- 
ing openings  in  the  stomach  and  intestine.  The  wall  of  the  stomach 
and  the  wall  of  the  intestine  are  then  united  all  around  the  circum- 
ference of  the  ring-blades  of  the  forceps,  except  for  the  small  space 
through  which  the  shanks  of  the  forceps  emerge.  This  union  should 
be  made  with  a  continuous,  non-penetrating  Lembert  suture  of  fine 
silk.  The  ring-blades  of  the  forceps  which  are  within  the  stomach 
and  intestine  retain  the  parts  in  accurate  apposition,  and  make  the 
application  of  the  suture  a  matter  of  comparative  ease. 

After  the  suture  has  been  applied  the  clamp  is  removed  from  the 
forceps,  which  is  thus  separated  into  its  two  component  parts,  the 
blades  of  each  of  which  form  but  half  a  ring;  these  are  withdrawn 
from  the  stomach  and  intestine,  first  one  and  then  the  other.  Finally 
the  small  opening  through  which  the  separated  forceps  were  with- 
drawn is  closed  with  one  or  two  additional  non-penetrating  Lembert 
sutures.  A  second  row  of  outside  non-penetrating  Lembert  sutures 
may  be  applied  all  around  the  first  row  of  sutures  if  desired,  in  order 
to  make  the  union  of  the  intestine  to  the  stomach  still  more  secure. 

Gastrojejunostomy  with  O'Hara  Forceps. — After  the  stom- 
ach and  intestine  have  been  drawn  out  through  the  abdominal  in- 
cision the  wall  of  each  is  picked  up  with  a  mouse-tooth  forceps  and 
securely  grasped  between  the  blades  of  one  of  the  forceps,  along  a 
line  corresponding  to  the  long  axis  of  each  organ,  in  the  same  manner 
as  one  would  grasp  the  prepuce  with  a  circumcision  clamp.  The 
length  of  the  wall  of  the  organ  thus  secured  between  the  blades  of 
the  forceps  will  vary  according  to  the  size  of  the  intended  open- 
ing. The  blades  of  the  forceps  are  graduated  so  that  there  should 
be  no  difficulty  in  securing  the  same  amount  of  each  organ,  and  this 
is  desirable.  As  the  wall  of  the  stomach  or  intestine  is  grasped  the 
tip  of  the  blade  should  reach  exactly  to  the  edge  of  the  process  thus 


OPERATIONS  UPON  THE  SMALL   INTESTINE.  325 

secured.  That  part  of  the  wall  of  the  stomach  and  intestine  which 
protrudes  beyond  the  blades  of  the  forceps  is  cut  away  with  the  knife 
or  scissors  fairly  close  to  the  blades.  The  two  forceps  are  then  united 
together  and  securely  locked  with  the  clamp,  and  we  are  ready  for 
the  next  step  of  the  operation,  the  suturing  of  the  wall  of  the  in- 
testine to  the  wall  of  the  stomach.  This  is  done  with  a  continuous, 
non-penetrating  Lembert  suture  of  silk.  Commencing  near  the  rivet, 
this  suture  is  carried  along  the  blades  of  the  forceps  toward  the  tip 
and  then  around  the  tip  of  the  forceps  and  back  again  upon  the  other 
side  to  a  point  near  the  rivet  where  the  suture  was  commenced.  As 
this  suture  progresses  it  serves  to  bury  the  blades  of  the  forceps 
beneath  it. 

The  junction  of  the  stomach  and  intestine  is  thus  complete 
except  for  the  small  space  through  which  the  forceps  emerge.  In 
applying  the  second  half  of  the  suture  it  will  be  necessary  to  turn 
the  forceps  over  and  with  them  the  stomach  and  intestine  in  order 
to  make  the  parts  upon  this  under  side  accessible.  After  the  stomach 
and  intestine  have  been  sutured  to  each  other  in  this  way  the  clamp  is 
removed  from  the  forceps  which  is  thus  separated  into  its  two  com- 
ponent parts.  One  forceps  is  unlocked  and  withdrawn.  The  second 
forceps  is  then  unlocked,  and,  after  being  passed  in  and  out  through 
the  opening  between  the  stomach  and  the  intestine  in  order  to  make 
certain  that  this  is  patent  and  that  none  of  the  stitches  have  been 
inadvertently  carried  across  to  the  opposite  margin  of  the  orifice, 
this  is  likewise  withdrawn.  The  small  opening  that  still  remains 
and  through  which  the  forceps  were  withdrawn  is  closed  with  one 
or  two  additional  non-penetrating  Lembert  sutures.  If  desired,  an 
additional  row  of  Lembert  sutures  may  be  placed  outside  the  first 
row  in  order  to  strengthen  the  union.  The  forceps  should  be  applied 
to  the  wall  of  the  stomach  and  wall  of  the  intestine  in  such  a  manner 
that  their  serrated  or  marked  surfaces  will  be  opposed  to  each  other 
when  they  are  joined  together. 

Posterior  Gastro-jejunostomy  Without  a  Loop  (Czerny). 
— In  order  to  eliminate  the  loop  effect  and  therefore  the  receptacle 
in  which  the  duodenal  and  stomach  contents  are  likely  to  accumulate, 
some  surgeons,  Czerny,  Hartmann,  and  others,  use  the  uppermost 
portion  of  the  jejunum,  within  a  few  inches  of  its  commencement 
at  the  duodenojejunal  junction,  for  the  purpose  of  establishing  the 
anastomosis  with  the  stomach.  This  portion  of  the  intestine  is  situ- 
ated close  to  the  posterior  wall  of  the  stomach  separated  from  it 


326  ABDOMEN  AND  BACK. 

by  the  interposed  transverse  mesocolon  only  and  just  above  the  level 
of  its  greater  curvature.  It  may  be  readily  attached  to  the  posterior 
wall  of  the  stomach  after  an  opening  has  been  made  in  the  transverse 
mesocolon. 

As  already  described  in  "Posterior  Gastrojejunostomy/'  the 
posterior  wall  of  the  stomach  is  exposed  by  reflecting  the  omentum 
and  transverse  colon  and  tearing  a  hole  in  the  transverse  mesocolon. 
The  uppermost  part  of  the  jejunum  is  secured  as  it  lies  to  the  left  of 
the  body  of  the  second  lumbar  vertebra  and  is  drawn  forward  and 
sutured  to  the  posterior  wall  of  the  stomach  near  its  lower  border  with 
a  continuous,  non-penetrating  Lembert  suture  of  silk.  Different 
from  the  usual  procedure,  the  gut  is  attached  along  a  line  running 
transverse  to  its  long  axis  and  about  half  way  around  its  circumfer- 
ence. The  needle  with  which  this  suture  has  been  applied  is  laid  aside 
temporarily  until  needed  later  to  complete  this  outside  serous  suture. 
In  front  of  the  suture  line  the  stomach  is  then  incised  and  likewise  the 
gut.  The  incision  in  the  gut  is  transverse  to  its  long  axis  and  reaches 
nearly  half  way  around  its  circumference.  The  edges  of  the  incisions 
in  the  stomach  and  gut  are  sewed  to  each  other,  all  around,  with  a 
continuous  catgut  suture.  The  second  half  of  the  outside  continuous 
Lembert  suture  is  then  applied  with  the  same  needle  and  silk  that 
were  used  to  apply  the  first  half  of  this  line  of  suture. 

The  anastomosis  between  the  stomach  and  intestine  may  also  be 
made  with  Murphy  button. 

This  method  of  gastrojejunostomy  is  said  to  be  free  from  the 
danger  of  the  so-called  "vicious  circle"  and  is  in  much  favor  with 
many  surgeons  at  the  present  time. 

Posterior  Gastrojejunostomy,  Y  Method  of  Eoux. — Theo- 
retically this  procedure  has  some  advantages  over  the  ordinary  method, 
but  as  a  matter  of  fact  considerably  more  time  is  required  for  its  ex- 
ecution, especially  at  the  hands  of  surgeons  less  familiar  with  the 
technique  of  intestinal  operations.  Time  is  a  consideration  of  seri- 
ous moment,  particularly  in  subjects  feeble  and  exhausted  from  pro- 
longed inanition. 

A  coil  of  gut  about  20  cm.  distant  from  the  commencement  of 
the  jejunum  is  selected.  The  contents  are  stripped  along  with  the 
fingers  and  a  gauze  strip  tied  around  the  gut.  Two  straight  compres- 
sion forceps  are  then  applied  to  the  gut  close  together  and  the  intestine 
divided  between  them  with  the  scissors,  the  cut  reaching  into  the  mesen- 
tery as  far  as  the  first  important  vascular  arch.    The  posterior  wall  of 


Fig.  150.— Posterior  Gastrojejunostomy  (Czerjiy).  Upper  part  of  jejunum 
anastomosed  to  posterior  wall  of  stomach  with  Murphy  button.  C,  colon; 
G.O.,  great  omentum;  J.,  jejunum;  P.,  pancreas;   8.,   symphysis  pubis. 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


327 


the  stomach  is  then  exposed  by  tearing  through  the  transverse  meso- 
colon, the  edges  of  the  opening  in  the  transverse  mesocolon  being  fixed 
to  the  wall  of  the  stomach  with  several  non-penetrating  silk  sutures. 
The  distal,  lower,  end  of  the  divided  gut  is  then  lifted  up  and  sewed 
into  an  opening  made  for  the  purpose  in  the  posterior  wall  of  the 


Pig.  151.— Posterior  Gastrojejunostomy  (Roux).  Upper  part  of  jejunum 
has  been  divided  and  the  lower  segment  sutured  into  an  opening  in  the 
posterior  wall  of  the  stomach  through  a  hole  in  the  mesocolon.  The  upper 
segment  has  been  sutured  into  an  opening  in  the  side  of  the  lower  segment. 


stomach  and  the  proximal,  upper,  end  of  the  gut  sutured  into  an  open- 
ing made  in  the  left  side  of  the  lower,  distal,  loop  of  the  gut — the  part 
that  has  been  sutured  to  the  stomach. 

The  method  of  uniting  the  ends  of  the  gut  to  the  edges  of  the 
openings  made  in  the  stomach  and  intestine  is  similar  to  that  employed 
in  joining  the  end  of  the  duodenum  to  the  stomach  in  "Pylorectomy 
(Koeher)."     (See  page  272.) 


328  ABDOMEN  AND  BACK. 

Finally  the  cut  edges  of  the  mesentery  are  sutured  to  the  adjacent 
underlying  mesocolon  and  mesentery  and  the  operation  thus  com- 
pleted. 

This  method  provides  very  excellent  drainage  for  the  stomach  and 
is  said  to  eliminate  almost  positively  the  danger  of  regurgitation  and 
"vicious  circle"  phenomena. 

Jejunostomy  (Maydl). — The  formation  of  a  jejunal  fistula  for 
the  purpose  of  feeding.  The  procedure  is  employed  in  those  cases  of 
inoperable  malignant  disease  of  the  pylorus  where  a  gastro- jejunostomy 
cannot  be  made. 

The  incision  is  placed  in  the  middle  line  above  the  umbilicus. 
Through  this  incision  the  operator  is  able  to  investigate  the  condition 
of  the  stomach,  etc. 

The  uppermost  portion  of  the  jejunum  is  sought  for  and  drawn 
out  of  the  incision.  This  part  of  the  gut  is  found  to  the  left  of  the 
body  of  the  second  lumbar  vertebra  and  may  be  identified  by  the  fact 
that  it  is  fixed  within  the  abdomen. 

A  loop  of  gut  about  20  cm.  distant  from  the  commencement  of 
the  jejunum  is  selected,  and,  after  it  has  been  stripped  between  the 
fingers  to  empty  it,  it  is  tied  off  with  two  pieces  of  gauze,  four  or  five 
inches  apart,  so  as  to  prevent  re-entrance  of  contents,  and  then  divided 
straight  across  with  the  scissors.  The  proximal  end  of  the  gut  which 
has  been  thus  divided  is  implanted  in  an  incision  which  is  made  in  the 
side  of  the  jejunum  about  20  cm.  still  farther  along,  nearer  the  ilio- 
csecal  valve.  This  coil  of  gut  is  also  emptied  by  stripping  between  the 
fingers  and  temporarily  occluded  by  tying  tapes  about  it  before  it  is 
incised.  This  step  of  the  operation  may  be  accomplished  either  with 
the  suture  or  the  Murphy  button  (see  "End-to-Side  Anastomosis"). 

The  distal  end  of  the  coil  of  gut  that  has  been  cut  across  is  then 
drawn  into  the  abdominal  incision  and  the  mesentery  stripped  back 
from  it  for  a  distance  of  about  2  cm.  so  as  to  leave  a  free,  protruding 
end  of  gut  that  long,  and  this  is  fixed  with  several  interrupted  catgut 
sutures  to  the  edges  of  the  lower  part  of  the  abdominal  incision,  down 
near  the  umbilicus.  Each  suture  should  penetrate  the  serous  and 
muscular  coats  of  the  gut  and  catch  the  edges  of  the  parietal  perito- 
neum and  deep  muscle  in  the  abdominal  incision. 

A  second  incision,  about  one  inch  long,  is  made  through  the  skin 
parallel  with  and  about  three-quarters  inch  distant  from  the  first  in- 
cision. This  second  incision  is  placed  alongside  the  lower  part  of  the 
first  one.    Between  the  two  incisions  the  bridge  of  integument  is  raised 


SURGICAL  ANATOMY  OF  THE  LARGE  INTESTINE,  ETC.         329 

on  the  handle  of  the  scalpel  and  the  protruding  end  of  the  gut  drawn 
through  into  the  second  incision,  where  it  is  fixed  with  from  four  to 
six  silk  sutures,  the  ends  being  left  long  to  facilitate  their  removal 
later.  The  first  incision  is  closed,  the  upper  part  with  penetrating 
sutures  of  silk;  corresponding  to  the  lower  part,  where  the  end  of  the 
gut  emerges,  the  sutures  go  through  the  integument  only. 

The  method  by  which  the  end  of  the  intestine  is  fixed  to  the  edges 
of  the  abdominal  incision  is  rather  analogous  to  the  Ssabanajew- 
Franck  plan  of  gastrostomy. 

THE  LARGE  INTESTINE  AND  VERMIFORM   APPENDIX. 

The  Surgical  Anatomy  of  the  Large  Intestine,  etc. — The  large 
intestine  may  be  distinguished  from  the  small  intestine  by  its  large 
caliber  and  by  its  sacculation;  attached  along  its  whole  length  is  the 
great  omentum  or  the  analogues  of  this  structure,  the  appendices 
epiploicae.  The  large  intestine  is  also  marked  by  three  longitudinal 
bands,  which  traverse  its  entire  length.  These  longitudinal  bands 
are  made  up  of  an  aggregation  of  the  longitudinal  muscular  fibers; 
one  of  them  is  found  along  the  mesenteric  border  of  the  gut,  another 
corresponds  to  the  attachment  of  the  great  omentum  and  the  little 
fatty  processes, — the  appendices  epiploicae, — and  the  third  is  located 
between  these  two. 

The  large  intestine  may  be  divided  into  three  parts :  the  csecum, 
colon  (ascending,  transverse,  descending,  and  sigmoid  flexure),  and 
the  rectum. 

The  C^cum  is  the  dilated,  pouched  commencement  of  the  large 
intestine.  It  is  found  in  the  right  iliac  fossa,  near  the  brim  of  the 
pelvis,  resting  upon  the  psoas  or  iliacus  muscle. 

It  is  provided  with  a  complete  peritoneal  investment,  is  mov- 
able, and  has  a  mesentery  which  is  short  and  serves  to  anchor  it  to 
the  posterior  abdominal  wall.  The  mesentery  is  sufficiently  long, 
however,  to  allow  this  part  of  the  intestinal  canal  to  be  drawn  out 
upon  the  abdominal  wall.  The  layers  of  the  mesocaecum  are  but 
loosely  adherent  to  each  other  and  may  be  readily  separated.  The 
csecum  is  continued  upward  into  the  ascending  colon  without  any 
definite  line  of  demarcation  between  them. 

The  Vermiform  Appendix  is  a  blind,  worm-like  process,  which 
is  given  off  from  the  inner  posterior  aspect  of  the  caecum  at  the 
point  where  the  longitudinal  bands  meet  and  from  one  to  one  and 


330  ABDOMEN  AND  BACK. 

one-half  inches  below  the  junction  of  the  small  intestine  with  the 
csecum.  It  is  found  lying  more  or  less  free  in  the  abdominal  cavity 
or  dipping  into  the  pelvis. 

The  base  of  the  appendix  corresponds  to  a  point  on  the  abdom- 
inal wall  called  "McBurney's  point,"  which  is  located  two  inches  to 
the  inner  side  of  the  anterior  superior  iliac  spine,  upon  a  line  drawn 
from  the  anterior  superior  iliac  spine  to  the  umbilicus. 

The  appendix  varies  much  in  size;  it  is  usually  as  thick  around 
as  a  lead  pencil  and  its  average  length  is  four  inches;  it  varies  from 
two  to  six  inches  and  may  be  longer.  Usually  it  is  a  hollow  tube, 
its  canal  extending  as  far  as  its  tip;  at  times,  however,  the  canal 
does  not  extend  to  the  tip  or  may  be  absent  entirely.  Its  inner  sur- 
face is  lined  with  mucous  membrane.  The  appendix  is  an  intra- 
peritoneal structure,  being  completely  invested  by  the  peritoneum, 
and  in  nearly  all  cases  it  is  provided  with  a  mesentery  of  its  own. 
This  mesentery  is  a  little  fold  derived  from  the  under  layer  of  the 
mesentery  of  the  small  intestine  where  the  latter  enters  the  csecum; 
it  incloses  the  appendix  between  its  folds,  and  usually  extends  only 
part  way  down  to  the  tip,  leaving  the  lower  third  or  half  of  the 
appendix  free.  This  mesentery  gives  one  the  impression  of  being 
too  short,  causes  the  appendix  to  present  its  curled-up  appearance, 
serves  to  limit  its  range  of  movement,  and  holds  it  in  close  relation 
with  the  csecum.  That  part  of  the  appendix,  toward  the  tip,  which  is 
unprovided  with  mesentery  is  freely  movable,  and  in  those  cases  in 
which  the  mesentery  is  nearly  or  entirely  absent  the  appendix  enjoys  a 
considerable  range  of  motion.  In  most  cases  the  appendix  is  more  or 
less  fixed  to  the  csecum  and  to  the  posterior  abdominal  wall  through 
its  mesentery.  Its  position,  as  regards  the  csecum,  varies  in  different 
individuals;  most  commonly  it  is  found  lying  upon  the  inner  or  left 
side  of  the  csecum,  with  its  tip  behind  the  ileum  and  pointing  upward 
in  the  direction  of  the  spleen.  In  other  cases  it  lies  upon  the  outer  or 
right  side  of  the  caecum,  rather  behind  it,  its  tip  pointing  upward 
toward  the  liver;  again,  it  may  be  found  dipping  down  into  the 
pelvis  or  lying  across  the  front  of  the  caecum.  In  any  of  these  posi- 
tions the  appendix  may  be  more  or  less  fixed  either  naturally  or  by 
inflammatory  adhesions. 

In  the  female  the  appendix  is  said  to  be  connected  with  the  broad 
ligament  by  a  thin  band,  the  so-called  appendiculo-ovarian  ligament, 
and  is  frequently  found  adherent  to  the  right  uterine  appendages  in 
disease  of  these  organs. 


SURGICAL  ANATOMY  OF  THE  LARGE  INTESTINE,  ETC.         331 

The  appendix  gets  its  arterial  supply  from  a  single  small  vessel 
derived  from  the  ileo-colic,  which  is  a  branch  of  the  superior  mesen- 
teric. The  venous  return  is  through  a  corresponding  single  venous 
channel  which  empties  into  the  superior  mesenteric  vein.  These 
vessels  run  parallel  with  the  appendix  in  the  edge  of  the  mesentery 
between  its  two  layers;  when  the  mesentery  is  absent  they  are  found 
upon  the  surface  of  the  appendix,  beneath  its  serous  coat.  In  the 
female  the  appendix  receives  an  additional  vessel  through  the  ap- 
pendiculo-ovarian  ligament.  The  appendix  is  dependent  for  its 
nutrition  upon  this  very  limited  blood-supply,  and  no  doubt  this 
arrangement  is,  at  least  in  part,  responsible  for  the  readiness  with 
which  the  wall  of  the  appendix  becomes  necrotic  when  its  circulation 
is  disturbed. 

Occasionally  some  difficulty  may  be  experienced  in  finding  the 
appendix.  If  the  longitudinal  bands  upon  the  caecum  are  traced 
downward,  they  will  be  found  to  lead  directly  to  the  point  where  the 
appendix  is  given  off,  and  therefore  these  bands  are  good  guides  to 
the  root  of  the  appendix. 

Just  above  the  root  of  the  appendix  the  small  intestine  ter- 
minates by  entering  the  caecum;  it  enters  the  caecum  upon  its  left 
side.  The  opening  between  the  ileum  and  caecum  is  guarded  by  the 
ileo-caecal  valve.  This  valve  consists  of  two  folds  of  mucous  mem- 
brane containing  some  circular  muscular  fibers.  These  folds,  pro- 
jecting into  the  lumen  of  the  gut,  allow  the  contents  of  the  ileum 
to  pass  freely  into  the  caecum,  but  prevent  the  reverse.  Fluids  in- 
jected through  the  rectum,  into  the  large  intestine,  cannot  pass  into 
the  ileum  unless  this  valve  is  forced,  and  that  requires  enough  press- 
ure to  threaten  the  rupture  of  the  large  intestine. 

The  Ascending  Colon. — This  is  the  continuation  upward  of 
the  caecum.  It  lies  close  to  the  posterior  wall  of  the  abdomen.  The 
ascending  colon  has  no  mesentery,  and  is  only  partly  invested  by  the 
peritoneum,  it  being  absent  upon  its  posterior  surface.  The  ascend- 
ing colon  ascends  along  the  outer  border  of  the  right  kidney,  lying 
partly  upon  the  kidney,  from  which  it  is  separated  by  some  inter- 
posed loose  connective  tissue  and  fat  only.  Continued  upward  as  far 
as  -the  under  surface  of  the  liver,  it  makes  a  turn — the  hepatic  flexure 
— and  becomes  the  transverse  colon.  The  under  surface  of  the  liver 
shows  a  shallow  depression  corresponding  to  the  hepatic  flexure,  arid 
here  the  colon  is  attached  to  the  liver  by  a  reflection  of  peritoneum, 
the  ligamentum  hepatico-colicum. 


332  ABDOMEN  AND  BACK. 

The  Transverse  Colon  stretches  from  right  to  left  across  the 
upper  part  of  the  abdominal  cavity,  lying  below  the  first  part  of  the 
duodenum  and  greater  curvature  of  the  stomach.  Close  to  the  spleen, 
on  the  left  side,  the  colon  makes  a  second  turn, — the  splenic  flexure, — 
and  from  this  point  is  continued  downward  as  the  descending  colon. 
At  the  splenic  flexure  the  colon  is  fixed  to  the  diaphragm  by  a  fold 
of  peritoneum,  the  ligamentum  phrenico-colicum. 

The  transverse  colon  is  completely  invested  by  peritoneum  and 
has  a  long  mesentery  which  suspends  it  from  the  posterior  wall  of 
the  abdomen.  The  transverse  colon  enjo}rs  considerable  freedom  of 
movement,  but  is  connected  with  the  greater  curvature  of  the  stomach 
by  the  peritoneum. 

In  the  very  young  child  the  connection  of  the  transverse  colon 
to  the  greater  curvature  of  the  stomach  does  not  exist,  because  the 
layers  of  peritoneum  which  invest  the  stomach  and  unite  with  each 
other  at  the  greater  curvature  to  form  the  great  omentum  have  not 
become  adherent  to  the  peritoneum  which  envelops  the  transverse 
colon;  this  does  not  occur  until  later  in  life  (see  Fig.  92). 

The  Descending  Colon  passes  downward  in  the  left  side  of 
the  abdominal  cavity,  lying  close  to  its  posterior  wall,  to  which  it  is 
partly  fixed.  It  has  no  mesentery,  is  only  partly  invested  by  the 
peritoneum,  and  cannot  be  drawn  out  upon  the  abdomen.  The  poste- 
rior wall  of  the  descending  colon,  which  is  devoid  of  peritoneum, 
lies  close  to  the  outer  border  of  the  left  kidney,  lying  partly  upon 
its  anterior  surface.     It  is  continued  below  into  the  sigmoid  flexure. 

The  Sigmoid  Flexure  is  the  last  part  of  the  colon;  it  is  a 
redundant  loop  of  gut  curved  upon  itself  and  lying  in  the  left  iliac 
fossa.  Its  caliber  is  rather  smaller  than  that  of  the  other  parts  of 
the  colon;  it  is  completely  invested  by  the  peritoneum,  and  has  a 
fairly  long  mesentery,  which  suspends  it  to  the  posterior  abdominal 
wall  and  permits  of  much  freedom  of  motion.  It  may  be  freely 
drawn  out  upon  the  abdominal  wall.  At  the  sacro-iliac  synchondrosis 
it  is  continued  down  into  the  pelvis  as  the  rectum. 

The  Blood-supply  of  the  Large  Intestine. — The  caecum,  ap- 
pendix, and  ascending  and  transverse  colon  are  supplied  by  branches 
which  are  given  off  from  the  right,  or  concave,  side  of  the  superior 
mesenteric  artery. 

The  descending  colon  and  sigmoid  flexure  are  supplied  by  the 
inferior  mesenteric,  which  comes  off  from  the  front  of  the  aorta  just 
below  the  origin   of  the   superior  mesenteric;    after   supplying  the 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  333 

parts  mentioned  this  vessel  dips  into  the  pelvis,  between  the  layers 
of  the  mesorectum,  to  supply  the  rectum  as  far  as  its  lower  end. 

The  arterial  branches  which  are  derived  from  the  superior,  and 
inferior  mesenteric  for  the  supply  of  the  ascending  and  descending 
colon,  as  they  pass  to  their  destination,  lie  upon  the  posterior  abdom- 
inal wall  covered  by  the  peritoneum  which  lines  the  back  of  the 
abdomen;  those  which  supply  the  caecum,  transverse  colon,  and  sig- 
moid flexure,  which  parts  of  the  large  intestine  are  provided  with  a 
mesentery,  reach  their  destination  between  the  layers  of  the  mesen- 
tery corresponding  to  the  part. 

The  ■  veins  have  a  course  similar  to  the  corresponding  arteries. 
The  inferior  mesenteric  joins  with  the  splenic  vein,  which,  in  turn, 
unites  with  the  superior  mesenteric  to  form  the  portal;  hence,  blood 
from  the  intestinal  tract  and  rectum1  must  first  traverse  the  portal 
circulation  (through  the  liver)  before  entering  the  general  circula- 
tion. Poisonous  matter  may  be  absorbed  from  the  intestinal  tract 
(colitis,  hemorrhoids,  etc.)  and  cause  thrombosis  in  the  veins  leading 
from  these  parts  or  may  result  in  abscess  in  the  liver,  etc. 

As  is  the  ease  with  the  vessels  of  the  small  intestine,  the  ter- 
minals of  the  arteries  that  are  distributed  to  the  large  intestine  do 
not  anastomose  freely  with  each  other ;  hence  division  of  a  considerable 
branch  will  often  result  in  gangrene  of  the  corresponding  part  of  the 
gut. 

OPERATIONS  UPON  THE  LARGE  INTESTINE. 

Colostomy. — The  formation  of  a  fistulous  opening  into  the  large 
intestine,  a  so-called  artificial  anus.  It  is  performed  for  obstruction 
in  the  large  intestine  or  rectum  or  as  a  preliminary  to  extirpation 
of  the  rectum.  This  operation  may  be  done  to  save  life  when  the 
danger  is  imminent  and  the  nature  of  the  lesion  or  the  patient's 
general  condition  precludes  the  probability  of  doing  a  radical  opera- 
tion with  a  reasonable  likelihood  of  success.  At  times  one  does  not 
decide  upon  the  formation  of  an  artificial  anus  until  after  an  ex- 
ploratory laparotomy  shows  its  necessity. 

Unless  one  can  previously  locate  the  seat  of  the  obstruction,  the 
exploratory  incision  is  best  placed  in  the  middle  line,  between  the 
umbilicus  and  the  symphysis,  and  the  artificial  anus  made  by  bring- 
ing the  most  accessible  portion  of  the  large  intestine  into  this  same 


1  Some    venous    blood    from    the    rectum    enters    the    general    circulation    direct 
through  the  middle  and  inferior  hemorrhoidal  veins. 


334  ABDOMEN  AND  BACK. 

incision  and  fixing  it  there.  The.  bowel  above  (proximal  to)  the  ob- 
struction will  be  found  distended,  and  that  below  (distal  to),  the 
obstruction,  diminished  in  caliber  or  collapsed. 

Descending  Colon. — If  the  obstruction  can  be  located  in  the 
sigmoid  flexure  or  rectum,  the  abdomen  should  be  opened  in  the  left 
iliac  region  and  the  lower  part  of  the  descending  colon  brought  up 
into  the  wound  and  fixed  to  its  edges. 

An  incision  about  three  inches  long  usually  suffices;  it  is  made 
parallel  with  Poupart's  ligament  commencing  above  about  one  inch 
above  the  anterior  superior  spine  and  terminating  below  about  one 
inch  above  the  middle  of  Poupart's  ligament. 

The  incision  is  carried  through  the  layers  of  the  abdominal  wall 
until  the  parietal  peritoneum  is  reached.  After  bleeding  points  have 
been  clamped  the  peritoneum  is  caught  up  with  two  mouse-toothed 
forceps,  and  between  them  a  small  opening,  large  enough  to  admit 
the  finger,  is  made  with  the  knife.  This  opening  is  enlarged  upon 
the  finger  with  a  blunt-pointed  scissors  so  as  to  correspond  in  length 
with  the  incision  in  the  skin.  The  edge  of  the  peritoneum,  upon  each 
side,  is  fixed  to  the  corresponding  margin  of  the  skin,  near  the  middle, 
with  two  or  three  catgut  sutures;  this  is  done  to  prevent  retraction 
of  this  layer  of  peritoneum.  Instead  of  placing  the  incision  as  indi- 
cated above  it  may  be  made  nearer  the  middle  line,  so  as  to  pass  be- 
tween the  fibers  of  the  rectus  muscles,  separating  between  these  bluntly 
with  the  handle  of  the  knife.  This  may  give  an  artificial  anus  which 
is  less  difficult  to  control. 

A  silk  stitch  (A,  Fig.  152)  is  passed  through  the  edges  of  the 
upper  part  of  the  incision,  through  all  the  layers,  including  the  skin 
and  the  edges  of  the  peritoneum;  a  second  similar  suture  (D,  Fig. 
152)  is  passed  through  the  lower  part  of  the  incision.  These  two 
sutures  are  not  tied.  The  lower  part  of  the  descending  colon  is  now 
sought  and  brought  up  into  the  wound.  In  order  to  secure  this  por- 
tion of  the  gut  two  fingers  are  introduced  into  the  abdomen  and  car- 
ried outward  and  backward,  along  the  inner  aspect  of  the  abdominal 
wall,  as  far  as  the  lumbar  region,  where  the  colon  is  found;  one  may 
meet  with  coils  of  the  small  intestine,  and  these  may  get  in  the  way 
of  the  fingers,  but  they  may  be  recognized  on  account  of  their  being 
entirely  surrounded  by  peritoneum  and  are  easily  pushed  aside;  the 
fingers  are  allowed  to  glide  from  the  posterior  wall  of  the  abdomen  on 
to  the  colon.  The  sigmoid  flexure  should  not  be  mistaken  for  the  de- 
scending colon,  because  this  part  of  the  gut  has  such  a  long  mesentery 


OPERATIONS  UPON  THE  LARGE  INTESTINE. 


335 


that,  if  used  to  form  the  artificial  anus,  it  may  after  a  time  become 
very  much  prolapsed,  and  this  is  undesirable.  Having  secured  the 
descending  colon,  we  select  a  portion  sufficiently  high  up  as  to  just 
allow  of  it  being  conveniently  drawn  into  the  incision.  If  it  can  be 
readily  drawn  out  upon  the  abdomen  we  may  know  that  we  have  the 
sigmoid  flexure,  and  should  then  try  to  obtain  a  portion  of  the  gut 
above  this. 


Fig.  152. — Colostomy.  The  wall  of  the  descending  colon  drawn  into  the 
incision  and  fixed.  A,  D,  stitches  which  pass  through  all  the  layers  of  the 
abdominal  wall,  including  the  peritoneum;  B,  C,  stitches  which  pass  through 
all  the  layers  of  the  abdominal  wall,  including  the  peritoneum,  but  catch  up 
the  wall  of  the  gut  as  well   in   their  course. 


While  that  part  of  the  gut  which  has  been  selected  is  steadied 
in  the  wound,  a  silk  stitch  (B,  Fig.  152)  in  a  curved  surgeon's  needle 
is  passed  through  the  upper  part  of  one  edge  of  the  incision,  through 
all  the  layers,  care  being  taken  to  include  the  peritoneum;  it  then 
passes  superficially  through  the  wall  of  the  gut,  picking  up  its  serous 
and  muscular  coats  and  taking  a  good,  broad  bite  or  several  bites, 
but  not  penetrating  into  its  lumen,  and  finally  is  brought  out  through 
the  opposite  edge  of  the  abdominal  incision.  A  second  stitch  (C,  Fig. 
152)  is  similarly  introduced  in  the  lower  part  of  the  abdominal  wound, 


336  ABDOMEN  AND  BACK. 

and  this  also  catches  the  wall  of  the  bowel  on  the  way.  These  two 
stitches  (B  and  C)  should  be  about  two  inches  apart  and  may  now  be 
tied,  likewise  the  two  stitches  previously  introduced  through  the  edges 
of  the  wound,  above  and  below,  and  the  bowel  is  thus  partially  fixed  in 
the  abdominal  incision. 

The  bowel  is  now  still  further  fixed  to  the  margins  of  the  ab- 
dominal incision  by  three  or  four  interrupted  fine  silk  sutures  on 
either  side;  each  one  of  these  should  secure  the  serous  and  muscular 
coats  of  the  bowel  and  the  edge  of  the  incision  in  the  abdomen,  in- 
cluding the  parietal  peritoneum  and  skin.  They  may  be  introduced 
with  a  small,  curved  surgeon's  needle. 

If  the  condition  is  not  very  urgent,  the  bowel  had  better  not  be 
opened  until  after  the  lapse  of  from  twenty-four  to  forty-eight  hours, 
thus  allowing  time  for  adhesions  to  form  and  shut  off  the  peritoneal 
cavity.  If  it  is  necessary  to  open  the  bowel  at  once  a  few  more  extra 
sutures  should  be  taken  in  order  to  secure  as  accurate  a  union  as  pos- 
sible between  the  surface  of  the  bowel  and  edges  of  the  abdominal 
incision. 

The  opening  in  the  bowel  may  be  made  with  a  knife,  the  bowel 
being  held  between  two  forceps,  or  it  may  be  made  with  a  Paquelin 
cautery;  it  should  be  sufficiently  large  to  allow  the  introduction  of 
a  fairly  thick,  snugly  fitting  tube.  Iodoform  gauze  is  packed  well 
about  this  tube  in  dressing  the  wound. 

Matdl  Method. — An  incision  is  made  as  above  and  two  or 
three  interrupted  catgut  sutures  are  introduced  on  each  side,  which 
serve  to  fix  the  parietal  peritoneum  to  the  skin.  A  silk  suture  (A  and 
D,  Fig.  152)  is  also  introduced  in  the  upper  and  in  the  lower  end  of 
the  incision.  These  are  left  untied  until  the  coil  of  gut  has  been 
secured  and  are  simply  for  the  purpose  of  diminishing  the  size  of  the 
incision.  A  convenient  portion  of  the  gut  is  seized  and  drawn  out 
through  the  abdominal  incision  and  a  glass  cylinder  or  an  artery  for- 
ceps or  a  strip  of  gauze  is  thrust  or  drawn  through  its  mesentery  and 
placed  at  right  angles  to  the  incision  in  the  abdomen,  so  as  to  retain 
the  loop  of  gut  in  situ,  outside  the  abdomen,  until  adhesions  have  had 
time  to  form.  The  loop  of  gut  may  be  still  further  secured  by  fixing 
it  to  the  edges  of  the  incision  with  several  catgut  sutures.  After  ad- 
hesions have  formed  the  gut  is  divided  completely  through,  down  to 
the  glass  cylinder,  forceps,  etc. 

If  a  portion  only  of  the  wall  of  the  bowel  is  fixed  to  the  opening 
in  the  abdomen,  as  described  in  the  first  operation,  there  will  be  per- 


Fig.  153. — Colostomy  (Maydl).  Loop  of  large  intestine  pulled  out  of  in- 
cision and  roll  of  gauze  drawn  through  its  mesentery  to  support  it  and  re- 
tain it   outside. 


OPERATIONS  UPON  THE  LARGE  INTESTINE. 


337 


Fig.  154. — Colostomy.  Antero-posterior  section  shows  the  wall  of  the  colon 
drawn  into  the  incision  in  the  abdomen.  C,  colon;  &,  symphysis  pubis;  U, 
umbilicus. 


Fig.  155. — Colostomy  (Maydl).  An  antero-posterior  section  showing  a 
whole  loop  of  intestine  drawn  out  of  the  incision  in  the  abdomen.  The  ap- 
posed walls  of  the  loop  become  joined  to  each  other  by  adhesion,  and  thus 
a  spur,  or  partition,  is  formed  which  prevents  the  contents  of  the  upper  part 
cf  the  gut  entering  the  lower  portion.    C,  S,  V,  same  as  Fig.  154. 


22 


338  ABDOMEN  AND  BACK. 

mitted  ready  escape  of  the  contents  of  the  bowel,  but,  at  the  same  time, 
the  likelihood  of  some  of  the  contents  passing  onward,  into  the  lower 
segment,  is  not  precluded.  This  condition  is  easily  restored  to  the 
normal,  so  that  this  method  of  operating  is  preferable  unless  we 
desire  the  artificial  anus  to  remain  permanently.  On  the  other  hand, 
if  a  whole  knuckle  of  gut  is  brought  out  of  the  wound,  as  described 
in  the  Maydl  operation,  a  "spur"  is  formed  which  acts  as  a  valve, 
directing  the  bowel  contents  out  through  the  opening  upon  the  abdo- 
men, and  at  the  same  time  hindering  the  passage  of  any  part  of  the 
bowel  contents  onward  into  the  lower  segment;  it  also  insures  the 
permanency  of  the  artificial  anus. 

Ascending  Colon. — If  the  growth — obstruction — involves  the 
transverse  or  descending  colon,  the  operation  may  be  performed  in 
a  similar  manner  upon  the  right  side  of  the  body;  in  this  case  the 
lower  part  of  the  ascending  colon  is  brought  into  the  wound  and  fixed. 

Resection  of  the  Caecum. — This  may  include,  in  addition  to  the 
caecum,  the  whole  or  a  part  of  the  ascending  colon  and  part  of  the 
ileum.     For  malignant  disease,  tuberculosis,  and  intussusception. 

If,  before  operating,  the  disease  can  be  located  in  this  part  of 
the  gut  or  a  tumor  felt,  the  incision  is  probably  best  placed  directly 
over  the  tumor  along  the  outer  border  of  the  right  rectus  muscle, 
in  the  linea  semilunaris.  If  the  incision  is  made  primarily  for  the 
purpose  of  exploration,  the  location  of  the  tumor  not  having  been 
previously  ascertained,  then  it  is  usually  placed  in  the  middle  line, 
reaching  from  the  umbilicus  downward,  toward  the  symphysis ;  through 
this  incision  the  caecum  may  also  be  excised  if  found  advisable.  In 
either  case  the  incision  must  be  long  enough  to  allow  sufficient  room 
for  work. 

If  the  incision  is  made  along  the  outer  border  of  the  rectus  it 
should  commence  about  one  inch  above  the  middle  of  Poupart's 
ligament  and  is  carried  in  a  direction  upward  to  a  point  located  mid- 
way between  the  umbilicus  and  the  anterior  superior  iliac  spine  or,  if 
necessary,  it  may  be  continued  farther  upward  toward  the  tip  of  the 
tenth  rib.  It  may  vary  from  five  to  ten  inches  in  length.  Having 
penetrated  through  the  abdominal  wall  down  to  the  parietal  perito- 
neum, this  layer  is  picked  up  with  two  toothed  forceps  and  incised 
between  them.  We  may  find  it  necessary  to  separate  some  adhesions 
before  the  caecum  is  exposed.  This,  together  with  the  adjoining  por- 
tion of  the  ileum,  is  then  brought  out  of  the  incision  upon  the  abdo- 
men.    If  tbe  caecum  is  the  seat  of  malignant  disease  and  already  so 


OPERATIONS  UPON  THE   LARGE  INTESTINE.  339 

fixed  within  the  abdomen  that  it  cannot  be  brought  out  of  the  wound, 
it  is  probably  inadvisable  to  proceed  with  the  extirpation,  because,  if 
one  is  not  reasonably  certain  of  removing  all  the  diseased  tissue,  the 
risk  is  out  of  proportion  to  the  best  result  that  can  be  hoped  for. 

The  caecum,  being  steadied  outside  the  abdominal  incision,  is 
surrounded  by  gauze  pads  to  protect  the  abdominal  cavity,  and  two 
strips  of  gauze  are  tied  about  the  bowel  beyond  the  part  which  is  to 
be  excised.  Before  tying  the  second  piece  of  gauze  the  segment  of  gut 
should  be  emptied  by  stripping  it  between  the  fingers.  The  gauze 
strips  should  be  placed  well  beyond  the  limits  of  the  part  to  be  excised, 
and  may  be  carried  around  the  gut  in  the  mouth  of  a  sharp-nosed 
artery  forceps  which  is  thrust  through  its  mesentery. 

The  mesentery,  corresponding  to  the  segment  of  gut  which  is 
to  be  excised,  is  tied  off  in  sections  with  catgut  ligatures.  The  liga- 
tures may  be  carried  in  the  eye  of  a  blunt  ligature  carrier  or  with 
a  pointed-nosed  artery  forceps.  Each  ligature  should  be  single  and 
placed  some  distance  away  from  the  gut,  so  as  to  leave  space  to  cut 
between  them  and  the  gut.  The  segment  of  gut  which  is  to  be  ex- 
cised is  detached  by  cutting  its  mesentery  between  the  ligatures  and 
the  gut.  One  should  take  care  to  excise  all  of  the  gut  whose  mesen- 
tery has  been  tied  off,  because,  if  an  end  of  the  gut  which  has  been 
deprived  of  its  mesentery,  and  hence  its  blood-supply,  is  left,  it  is 
slow  to  unite  and  may  become  gangrenous.  It  remains  to  divide  the 
gut  above  and  below,  thus  removing  the  diseased  segment.  This  is 
done  with  a  long,  straight  scissors  in  one  sweep,  long  clamps  having 
been  previously  placed  upon  the  gut  to  close  the  diseased  segment  in 
order  to  prevent  the  escape  of  its  contents  when  it  is  cut. 

Instead  of  proceeding  as  above,  one  may,  after  the  strips  of  gauze 
and  clamps  have  been  applied  about  the  gut,  first  resect  the  diseased 
segment  of  the  gut  above  and  below  and  then  tie  off  the  correspond- 
ing part  of  the  mesentery  in  sections  as  described. 

We  are  then  ready  for  the  final  step  of  the  operation,  the  restora- 
tion of  the  continuity  of  the  alimentary  canal  by  joining  the  ileum 
to  the  colon  (ileo-colostomy),  and  this  may  be  accomplished  by: — 

1.  End-to-end  anastomosis. 

2.  Lateral  anastomosis  (with  suture  or  McGraw's  rubber  liga- 
ture or  Laplace  or  O'Hara  forceps,  etc.). 

3.  Lateral  implantation  (with  suture  or  Murphy  button). 
End-to-End  Anastomosis. — This  method  may  be  employed  if 

both  ends  of  the  gut  which  are  to  be  united  are  of  the  same  caliber; 


340  ABDOMEN  AND  BACK. 

this  condition  at  times  exists,  owing  to  the  fact  that  the  obstruction 
in  the  caecum  or  at  the  ileo-caecal  opening  may  have  caused  a  dilata- 
tion and  hypertrophy  of  the  ileum,  the  large  intestine  at  the  same 
time  having  become  more  or  less  diminished  in  caliber. 

The  anastomosis  may  be  made  with  a  double  row  of  silk  sutures, 
the  first  row  passing  through  all  the  layers  of  the  wall  of  the  intestine, 
including  the  mucous  membrane  and  serous  layers,  and  applied  in 
such  a  manner  that  the  sutured  edges  are  turned  inward  into  the 
lumen  of  the  gut;  this  first  row  of  sutures  may  be  continuous  and 
applied  with  a  medium-sized  curved  surgeon's  needle.  The  second 
row  of  sutures  (Lembert)  is  passed  through  the  serous  and  muscular 
coats  only, — they  do  not  penetrate  into  the  lumen  of  the  bowel, — and 
serve  to  bury  the  first  row.  This  second  row  may  also  be  continuous. 
In  applying  both  of  these  rows  great  care  should  be  exercised  to  include 
the  serous  coat,  especially  near  the  mesenteric  attachment.  This  is 
the  weak  spot,  especially  in  suturing  the  large  intestine.  The  end-to- 
end  anastomosis  may  also  be  accomplished  with  suture  according  to  the 
method  of  Mounsell  or  of  Connell  or  with  a  Murphy  button  of  the 
largest  size,  Laplace  and  O'Hara  forceps,  etc.  If  the  two  ends  of  gut 
are  of  unequal  lumen  the  larger  must  be  reduced  by  infolding  a  por- 
tion so  that  it  will  correspond  in  size  with  the  smaller  (see  "End-to- 
End  Anastomosis,  Small  Intestine"). 

Lateral  Anastomosis. — This  is  a  satisfactory  method  of  re- 
storing the  continuity  of  the  intestinal  canal,  particularly  if  the  ends 
are  of  unequal  size;  for  example,  in  joining  the  ileum  to  the  caecum 
or  colon  (see  also  "Lateral  Anastomosis,  Small  Intestine"). 

The  cut  edge  of  each  segment  of  gut  is  inverted,  a  margin  of  from 
three-fourths  to  one  inch  being  turned  in  and  the  opening  closed  with 
a  continuous  silk  stitch,  which  passes  through  the  serous  and  muscu- 
lar coats,  always  taking  special  care,  particularly  at  the  mesenteric 
border,  to  appose  serous  surfaces  to  each  other.  A  second  continuous 
silk  suture  is  then  introduced;  this  second  suture  also  includes  only 
the  serous  and  muscular  coats  and  serves  to  bury  the  first  line  of 
suture. 

The  ends  of  the  bowel  which  have  been  thus  closed  up  are  now 
placed  side  to  side,  overlapping  each  other  for  a  distance  of  five  or 
six  inches,  and  they  are  then  united,  surface  to  surface,  for  a  distance 
of  four  or  five  inches  with  a  continuous  Lembert  suture  of  fine  silk. 
This  forms  the  first  half  of  the  "outside  serous  ring"  suture,  and  when 
completed  the  needle  with  the  suture  left  long  is  temporarily  laid  aside. 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  341 

An  incision  is  then  made  in  each  segment  of  the  gut  three  to 
four  inches  long,  but  not  so  long  as  the  line  of  the  Lembert  suture 
(one  inch  shorter),  and  at  a  distance  of  about  one-fourth  inch  away 
from  the  line  of  the  Lembert  suture.  The  corresponding  edges  of 
these  incisions  are  joined  together  all  around  with  a  continuous  over- 
hand silk  or  catgut  suture,  which  includes  all  the  coats  of  the  gut 
and  which  may  be  introduced  with  a  large,  straight  needle.  After 
the  edges  of  these  openings  have  been  thus  united,  the  needle  with 
which  the  first  half  of  the  "outside  serous  ring"  suture  was  made  is 
again  taken  up  and  the  second  half  of  the  "outside  serous  ring," 
Lembert  suture,  inserted.  The  gut  is  kept  free  of  contents  during 
the  operation,  as  usual,  by  constricting  it  with  strips  of  gauze  passed 
around  each  segment  of  gut  beyond  the  site  of  the  operation.  The 
margins  of  the  gut  may  be  wiped  off  with  a  moist  bichloride  pad  as 
often  as  they  are  soiled  by  escaping  intestinal  contents. 

Having  completed  the  union  of  the  two  segments  of  gut,  any 
rent  or  opening  which  is  left  in  the  mesentery  may  be  closed  with 
several  catgut  sutures  and  the  parts  returned  to  the  abdomen. 

The  lateral  anastomosis  may  also  be  made  with  McGraw's  rubber 
ligature  in  a  manner  analogous  to  that  described  in  gastrojejunos- 
tomy or  with  the  Laplace  or  O'Hara  forceps. 

End-to-Side,  Lateral  Implantation. — The  technique  of  this 
operation  is  analogous  to  Kocher's  gastro-duodenostomy  (see  "Py- 
lorectomy").  This  is  probably  not  as  satisfactory  a  procedure  as 
either  the  end-to-end  or  lateral  anastomosis  method.  It  may  be  done 
by  suture  or  with  a  Murphy  button.  After  infolding  and  closing  the 
end  of  the  large  intestine  the  end  of  the  ileum  is  united  to  the  edges 
of  a  slit  which  is  made  in  the  large  intestine  opposite  its  mesenteric 
border,  the  union  being  accomplished  either  by  suture  or  with  a 
Murphy  button. 

By  any  of  these  methods  the  ileum  may  be  joined  to  any  part  of 
the  large  intestine.  Owing  to  the  frequent  imperfections  of  the  serous 
coat  at  the  mesenteric  border  of  the  large  intestine,  the  suture  in  all 
these  operations  is  always  somewhat  doubtful,  and  it  may  be  wise  in 
many  cases  to  leave  a  strip  of  gauze,  reaching  from  the  sutured  gut 
through  the  abdominal  incision,  for  drainage  in  case  of  leakage. 

Ileo-colostomy  Without  Resection  of  the  Caecum  or  Colon. — This 
operation  may  be  done  in  cases  of  obstruction  at  the  ileo-csecal  valve 
when  the  advisability  of  a  more  radical  operation — resection — is 
doubtful.    A  lateral  anastomosis  may  thus  be  made  between  the  ileum 


342  ABDOMEN  AND  BACK. 

and  the  ascending  colon,  or,  if  the  obstruction  is  located  in  another 
part  of  the  colon,  the  anastomosis  may  be  made  between  the  ileum  and 
the  sigmoid  flexure.  Care  should  be  taken  to  secure  a  coil  of  small 
intestine  as  low  down,  near  the  caecum,  as  possible;  so  that  the  nu- 
trition of  the  patient  may  not  be  seriously  interfered  with.  The  details 
of  the  operation  are  similar  to  those  described  in  the  preceding  para- 
graphs (see  "Lateral  Anastomosis"). 

Resection  of  the  Sigmoid  Flexure. — This  operation  is  usually 
performed  for  malignant  obstruction.  This  part  of  the  large  intestine 
is  a  favorite  seat  of  malignant  disease. 

The  incision  is  probably  best  made  analogous  to  that  for  excision 
of  the  caecum,  but  upon  the  other  side  of  the  abdomen,  along  the  outer 
border  of  the  left  rectus,  commencing  below,  about  one  inch  above 
the  middle  of  Poupart's  ligament.  The  sigmoid  may  also  be  resected 
through  an  incision  in  the  linea  alba,  extending  from  the  umbilicus 
downward  to  the  symphysis  pubis  if  such  an  incision  has  already  been 
made  for  the  purpose  of  exploration  before  the  growth  was  definitely 
located. 

The  sigmoid,  owing  to  its  long  mesentery,  may  be  readily  drawn 
out  through  the  abdominal  incision.  It  is  surrounded  by  gauze  pads 
to  protect  the  abdominal  cavity,  and  after  the  mesentery,  which  is 
usually  quite  long,  has  been  tied  off  in  sections,  that  part  of  the  bowel 
which  is  to  be  resected  is  clamped  off,  cut  free  from  its  mesenteric 
attachment,  and  finally  excised.  The  ends  of  the  bowel  are  then 
united,  end  to  end,  by  suture  or  with  a  large  Murphy  button,  as  de- 
scribed in  resection  of  the  caecum,  etc.  The  same  care,  etc.,  should  be 
exercised  in  suturing  near  the  mesenteric  attachment  to  include  the 
serous  coats. 

After  the  sigmoid  has  been  resected  each  end  of  the  bowel  may  be 
inverted  and  closed  with  suture  and  a  lateral  anastomosis  then  made 
as  already  described  in  the  preceding  paragraphs  in  connection  with 
resection  of  the  caecum. 

If  the  sigmoid  is  fixed  and  the  neighboring  parts  already  infil- 
trated, it  may  be  better  to  make  an  artificial  anus  above  the  seat  of 
obstruction  and  omit  the  radical  operation. 

The  colon  has  also  been  resected  at  the  hepatic  and  the  splenic 
flexures,  the  incision  being  made  above,  along  the  outer  border  of 
the  corresponding  rectus,  or  in  the  middle  line,  from  the  ensiform 
cartilage  downward  to  or  beyond  the  umbilicus.  The  continuity  of 
the  canal  may  be  restored  by  any  one  of  the  methods  described  above. 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  343 

OPERATIONS  UPON  THE  VERMIFORM  APPENDIX. 

Appendicectomy. — Eemoval  of  the  appendix. 

As  performed  in  eases  of  chronic  relapsing  catarrhal  and  re- 
current appendicitis,  there  being  no  abscess  present.  In  these  cases 
the  incision  in  the  abdomen  is  closed  immediately  upon  completion 
of  the  operation  and  without  drainage. 

The  Incision  is  oblique  from  above,  downward  and  inward,  and 
should  be  about  three  inches  long.  Some  operators  use  a  much  shorter 
incision.  It  is  well  to  commence  with  a  short  incision,  which  may  be 
lengthened  later  should  it  become  necessary.  In  fat  subjects  it  is  well 
to  make  a  liberal  incision  through  the  integument  and  fat.  In  pene- 
trating through  the  aponeurosis  and  muscle,  etc.,  the  incision  may  be 
made  as  short  as  is  compatible  with  the  proper  performance  of  the 
operation. 

The  incision  should  be  placed  about  one  and  one-half  inches  to 
the  inner  side  of  the  anterior  superior  iliac  spine,  crossing,  almost 
at  a  right  angle,  a  line  drawn  from  the  anterior  superior  spine  to  the 
umbilicus  and  so  arranged  that  one-third  of  the  length  of  the  incision 
is  above  the  line  and  two-thirds  below  it. 

All  bleeding  points  should  be  clamped  but  need  not  be  ligated 
immediately,  as  they  usually  stop  after  the  forceps  have  been  applied 
for  a  few  minutes.  The  aponeurosis  of  the  external  oblique  is  ex- 
posed and  divided,  separating  between  its  fibers  along  a  line  corre- 
sponding to  the  skin  incision.  The  muscular  fibers  of  the  internal 
oblique  are  then  exposed  and  incised,  together  with  those  of  the 
transversalis,  which  muscle  lies  beneath  the  internal  oblique;  the 
fibers  of  these  muscles  are  divided  at  right  angles  to  their  course. 
Finally  the  incision  is  carried  through  the  fascia  transversalis  and 
parietal  peritoneum,  the  latter  being  picked  up  with  two  mouse- 
toothed  forceps  and  divided  between  these.  The  gut  as  it  lies  be- 
neath the  peritoneum  may  be  adherent  to  the  latter,  and  therefore 
care  should  be  exercised  in  cutting  through  the  peritoneum  not  to 
wound  the  gut.  It  may  not  be  necessary  to  divide  the  muscles  for 
the  whole  length  of  the  skin  incision.  In  many  cases,  if  the  mus- 
cular layer  is  divided  for  a  distance  corresponding  to  the  middle  half 
of  the  length  of  the  skin  incision,  this  will  suffice,  and,  if  necessary, 
later  the  incision  in  the  muscles  can  be  lengthened  above  and  below. 

In  closing  this  incision  each  layer  should  be  united  separately: 
first,  the  parietal  peritoneum  with  a  continuous  catgut  stitch;    then 


344  ABDOMEN  AND  BACK. 

the  transversalis  fascia  and  the  muscles  with  a  second  continuous 
catgut  stitch;  then  the  aponeurosis  of  the  external  oblique,  also 
with  a  continuous  catgut  suture;  and  finally  the  skin,  with  a  catgut 
stitch.  On  account  of  the  division  of  the  abdominal  muscles  a  ventral 
hernia  is  not  unlikely  to  follow  the  operation. 

The  McBurnbt  Gridiron  Incision. — This  method  obviates  the 
likelihood  of  subsequent  hernia  and  should  be  employed  whenever 
possible.  The  cut  through  the  skin  is  the  same  as  that  described  in 
the  preceding  paragraphs;  the  aponeurosis  of  the  external  oblique  is 
split  by  separating  between  its  fibers,  and  then  two  broad,  sharp  re- 
tractors are  introduced,  and,  retracting  the  skin  and  aponeurosis,  the 
muscular  fibers  of  the  internal  obliqiie  are  exposed;  these  are  not  cut, 
but  are  separated  with  the  handle  of  the  knife  in  the  direction  of  the 
fibers,  which  is  nearly  at  a  right  angle  to  the  direction  of  the  skin 
incision.  The  fibers  of  the  transversalis  muscle  are  next  exposed  and 
treated  in  a  similar  manner.  Two  broad,  blunt  retractors  are  then 
introduced  and  the  edges  of  the  muscles  drawn  apart,  when  the  trans- 
versalis fascia  is  exposed  and  incised,  and  finally  the  peritoneum. 
These  last  two  layers  are  divided  in  the  same  direction  as  the  internal 
oblique;  i.e.,  at  right  angles  to  skin  incision.  They  are  picked  up 
with  two  mouse-toothed  forceps  and  divided  between  these,  together 
or  separately,  in  order  to  avoid  injuring  the  underlying  gut. 

Two  sets  of  retractors  are  necessary  to  hold  the  wound  open: 
one  set,  sharp,  for  the  edges  of  the  skin  and  aponeurosis  of  the  ex- 
ternal oblique,  retracting  from  side  to  side;  the  other  set,  blunt, 
for  the  muscles  and  deeper  layers,  retracting  from  above  and  from 
below.  We  have  thus  a  four-sided  opening  in  the  abdomen  which 
may  be  enlarged  by  prolonging  the  separation  and  incision  in  the 
different  layers.  In  closing  this  incision  the  edges  of  the  peritoneum 
are  first  brought  together  with  a  continuous  catgut  stitch.  The  edges 
of  the  muscles  of  themselves  return  to  place  and  are  secured  by  two  or 
three  interrupted  catgut  sutures,  which  include  the  transversalis  fascia 
also  in  their  bite.  The  aponeurosis  of  the  external  oblique  is  sewed 
with  a  continuous  catgut  suture  from  above  downward,  and  the  skin 
then  closed  with  an  intracuticular  catgut  suture. 

The  Battle  Incision. — A  perpendicular  incision,  four  inches 
in  length,  which  is  placed  one  and  one-half  inches  to  the  inner  side 
of  the  linea  semilunaris,  is  made  through  the  skin  and  fat,  down  to 
the  aponeurosis  of  the  external  oblique.  The  lower  two-thirds  of 
this  incision  should  be  below  a  line  which  is  drawn  from  the  anterior 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  345 

superior  spine'  to  the  umbilicus.  The  aponeurosis,  which  really  forms 
the  anterior  layer  of  the  sheath  of  the  rectus,  is  then  divided  to  cor- 
respond with  the  skin  incision  and  the  fibers  of  the  rectus  thus  ex- 
posed. The  rectus  muscle  is  not  cut,  but  is  drawn  inward  until  its 
outer  edge  is  reached,  and,  while  it  is  thus  held  with  a  blunt  retractor, 
the  posterior  layer  of  its  sheath  is  incised  for  a  length  corresponding 
with  the  incision  in  its  anterior  layer.  This  incision  through  the 
posterior  layer  of  the  rectus  sheath  is  not  placed  immediately  behind 
the  incision  in  the  anterior  layer,  but  rather  external  to  it.  The  parts 
being  well  retracted,  good  access  is  had  to  the  abdominal  cavity.  In 
closing  this  opening  each  layer  is  sutured  separately:  first,  the  peri- 
toneum, and  then  the  opening  in  the  posterior  layer  of  the  sheath  of 
the  rectus.  The  rectus  muscle  is  allowed  to  resume  its  normal  position, 
and  a  suture  is  placed  in  the  anterior  layer  of  its  sheath.  These 
sutures  are  all  continuous  and  of  simple  catgut;  finally  the  skin  in- 
cision is  closed.    This  incision  also  diminishes  the  liability  to  hernia. 

After  having  opened  into  the  abdomen  by  any  of  the  methods 
described  above,  we  may  proceed  with  the  next  step  of  the  operation, 
the  search  for  the  appendix.  At  times  it  may  be  found  presenting  at 
once  in  the  wound,  more  or  less  changed,  thickened,  etc.,  or,  occasion- 
ally being  bound  down  and  fixed  within  the  abdomen  by  adhesions, 
it  does  not  come  into  view,  and  then  it  will  be  necessary  to  search 
for  it. 

The  appendix  may  be  directed  downward  and  may  dip  into  the 
pelvis,  or,  with  its  tip  pointed  upward,  it  may  lie  to  the  outer  or  to 
the  inner  side  of  the  caecum.  It  may  be  more  or  less  confined  in  any 
of  these  positions  by  its  mesentery  or  by  adhesions.  If  difficulty  is 
experienced  in  finding  the  appendix,  the  caecum  may  be  brought  out 
of  the  wound  to  serve  as  a  guide.  The  caecum-  is  identified  by  its 
sacculation,  by  the  little  fatty  processes  attached  to  it,  and  by  its 
longitudinal,  white  striae,  two  of  which  can  usually  be  seen:  if  these 
striae  are  followed  they  will  be  found  to  lead  down  to  the  point  where 
the  appendix  is  given  off. 

The  appendix  is  gently  liberated  from  its  adhesions  with  the 
fingers, — there  is  no  danger  of  hemorrhage  in  this  procedure, — and 
gradually  it  is  brought  out  of  the  wound,  the  caecum  being  at  the 
same  time  returned  into  the  abdomen.  Care  should  be  exercised  to 
detach  the  appendix  all  the  way  back  as  far  as  its  root. 

It  is  wise,  before  beginning  to  free  the  appendix,  to  introduce 
into  the  wound  one  or  more  gauze  pads  to  protect  the  peritoneal 


346 


ABDOMEN  AND  BACK. 


cavity  during  the  removal  of  the  appendix  and  in  the  event  of  unex- 
pectedly meeting  a  small  collection  of  pus. 

After  the  appendix  has  been  sufficiently  freed  it  'is  held  in  the 
wound  or  outside  the  abdominal  incision,  and  after  having  properly 


Fig.  156. — Appendix.    Meso-appendix  shown. 


arranged  the  gauze  pads  so  as  to  protect  the  peritoneal  cavity,  we 
proceed  at  once  to  tie  off  the  mesentery  of  the  appendix.     This  is 


Fig.   157.—  Appendicectomy.     Appendix   (A)   ligated  without  inversion   and 
amputated;   M,   meso-appendix   tied   off. 

done  by  transfixing  the  mesentery  close  to  the  appendix  and  near  its 
root  with  a  ligature  carrier  or  with  a  straight  or  curved  needle  carry- 
ing a  piece  of  No.  2  simple  catgut.  This  ligature  is  tied  and  the 
appendix  then  cut  away  from  the  mesentery,  cutting  between   the 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  347 

appendix  and  the  ligature  with  the  scissors.  The  appendix  being 
thus  separated  from  its  mesentery  all  the  way  back  to  its  root,  we  are 
ready  to  proceed  with  the  final  step  of  the  operation, — the  removal  of 
the  appendix.     This  may  be  done  in  one  of  several  ways. 

1.  Ligature  Without  Inversion. — After  the  mesentery  has 
been  tied  off  and  cut  away,  from  the  appendix  with  the  scissors,  a 
catgut  ligature  (No.  2)  is  tied  securely  around  the  appendix  about 
one-fourth  inch  distant  from  its  root;  the  ends  of  this  ligature  are 
left  long  to  serve  as  a  temporary  tractor.  The  appendix  is  then  seized 
with  an  artery  clamp  upon  the  distal  side  of  the  ligature  to  prevent 
leakage  when  it  is  cut,  and  with  a  straight  scissors  it  is  amputated 
between  the  clamp  and  ligature.  While  the  stump  of  the  appendix 
is  steadied  by  making  traction  with  the  ligature,  which  was  left  long 
intentionally  for  that  purpose,  the  raw  end  of  the  stump  is  touched 
with  pure  carbolic  acid  on  a  very  small  swab  or  else  it  is  cauterized 
with  a  pointed  Paquelin.  Some  aristol  may  then  be  rubbed  in,  the 
ligature  cut  short,  and  the  stump  of  the  appendix  allowed  to  drop 
back  into  the  abdomen.  This  is  a  safe  way  of  dealing  with  the  ap- 
pendix stump  and  is  especially  satisfactory  in  cases  where  unusual 
difficulty  would  be  experienced  in  inverting  it,  etc. 

2.  Inversion  of  the  Stump  of  the  Appendix  Without  Liga- 
ture.— After  the  mesentery  has  been  tied  off  and  cut  away  from  the 
appendix  and  without  applying  a  ligature  around  its  root,  the  ap- 
pendix is  seized  with  an  artery  clamp  and  amputated  within  one-half 
inch  of  its  junction  with  the  caecum.  The  short  stump  of  the  ap- 
pendix that  remains  is  then  inverted  into  the  lumen  of  the  caecum, 
and  the  opening  in  the  caecum  corresponding  to  the  base  of  the  in- 
verted appendix  stump  is  closed  with  several  fine,  silk  Lembert  su- 
tures. One  or  two  of  these  sutures  may  be  introduced  before  the 
appendix  is  amputated  so  that  they  may  be  drawn  tight  as  the  stump 
is  inverted.  There  is  no  bleeding  from  the  stump  of  the  appendix. 
The  amputation  of  the  appendix  may  be  accomplished  with  the 
scissors  or  the  Paquelin.  This  is  a  very  simple  and  satisfactory  way 
of  treating  the  appendix. 

3.  Inversion  of  the  Stump  of  the  Appendix  with  Purse- 
string  (Dawbarn). — After  the  mesentery  has  been  ligated  and  cut 
free  from  the  appendix,  the  latter  is  steadied  and  a  silk  purse-string 
suture  introduced  into  the  wall  of  the  caecum  so  as  to  surround  the 
root  of  the  appendix  at  a  distance  of  about  one-fourth  inch  all  around. 
This  stitch  should  include  only  the  serous  and  muscular  coats  of  the 


348  ABDOMEN  AND  BACK. 

caecum;  it  should  not  penetrate  into  the  lumen  of  the  bowel.  The 
purse-string  suture  is  not  drawn  tight  nor  tied,  but  the  first  double 
loop  of  a  surgeon's  knot  is  taken.  Then,  without  applying  any  liga- 
ture around  its  root  the  appendix  is  seized  with  an  artery  forceps  and 
cut  away  with  the  scissors,  leaving  a  stump  about  one-half  inch  long. 
The  stump  does  not  bleed.  One  may  amputate  the  appendix  with  a 
Paquelin  instead  of  a  scissors.  A  thin  artery  forceps  or  the  ends  of 
a  thumb  forceps  are  next  introduced  into  the  canal  of  the  stump  like 
a  glove  stretcher,  and  with  this  the  stump  is  stretched.  The  cut  end 
of  the  stump  is  then  seized  with  the  thumb  forceps  or  thin  artery 
forceps  and  inverted  into  the  caecum;  it  is  turned  "outside  in"  like 
a  reversed  glove  finger.     The  forceps  is  then  withdrawn,  and  at  the 


ILEUM 


Fig.  158.— Appendicectomy.    A  portion  of  the  wall  of  the  caecum  removed  in  order 
to  show  the  inverted  appendix  stump   (A).    M,   meso-appendix  tied  off. 

same  time  the  purse-string  is  drawn  tight,  thus  leaving  the  inverted 
stump  presenting  into  the  caecum  and  closing  the  opening  in  the 
caecum.  If  thought  necessary,  one  may  still  further  secure  the  open- 
ing in  the  caecum  by  applying  two  or  three  Lembert  stitches  in  addi- 
tion to  the  purse-string.  This  is  a  very  convenient  and  safe  method 
of  disposing  of  the  stump  of  the  appendix. 

4.  Inversion  of  the  Appendix  (Edebohls). — This  procedure 
is  applicable  to  cases  of  catarrhal  appendicitis  that  do  not  demand 
amputation  of  the  organ.  It  may  also  be  practiced  incidentally  dur- 
ing the  course  of  other  abdominal  operations  in  order  to  preclude  the 
possibility  of  the  appendix  becoming  a  source  of  trouble  at  some  future 
time.  The  meso-appendix  is  first  tied  off  close  to  the  root  of  the  ap- 
pendix and  then  cut  away  from  the  appendix  for  its  whole  length. 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  349 

The  point  of  a  probe  is  then  applied  to  the  tip  of  the  appendix,  and 
with  this  the  appendix  is  turned  "outside  in"  into  the  lumen  of  tne 
caecum  as  one  would  reverse  the  finger  of  a  glove.  After  the  appendix 
has  been  inverted  into  the  caecum  and  while  it  is  thus  held  with  the 
probe  by  which  it  was  inverted  one  or  two  stitches  of  silk  are  taken 
so  as  to  close  the  orifice  that  corresponds  to  the  root  of  the  turned-in 
appendix.  The  probe  is  then  withdrawn  and  if  necessary  another 
stitch  may  be  taken.  After  the  mesentery  has  been  ligated,  it  should 
be  trimmed  away  very  close  to  the  appendix  in  order  to  diminish  the 
bulk  of  the  organ  and  facilitate  the  process  of  inverting  it  into  the 
caecum. 

The  stitches  that  unite  the  margins  of  the  orifice  that  corresponds 
to  the  root  of  the  appendix  serve  to  retain  the  appendix  in  its  new 
inverted  condition;  they  are  usually  of  silk  and,  of  course,  are  non- 
penetrating. 

In  connection  with  any  of  these  methods  the  stump  of  the  mesen- 
tery may,  in  addition,  be  sutured  over  the  site  of  the  inverted  appendix 
stump. 

During  any  of  these  manipulations  it  is  necessary  for  the  operator 
or  an  assistant  to  steady  the  caecum,  grasping  it  between  the  fingers 
with  a  gauze  pad,  which  gives  a  better  hold  and  at  the  same  time 
protects  it  from  becoming  soiled. 

The  incision  in  the  abdomen  is  finally  closed,  as  indicated  above, 
without  drainage.  Proper  apposition  and  primary  healing  of  the 
incision  are  necessary  to  secure  the  patient  from  the  liability  to  sub- 
sequent ventral  hernia. 

Some  surgeons  recommend  this  plan  of  closure  without  drainage 
even  if  an  abscess  has  been  encountered  provided  it  is  small,  circum- 
scribed, and  can  be  thoroughly  emptied  and  sterilized. 

Operations  for  Appendicular  Abscess. — Cases  that  go  on  to  sup- 
puration, resulting  in  the  formation  of  a  localized  intraperitoneal 
abscess  which  is  shut  off  from  the  general  peritoneal  cavity  by  adhe- 
sions between  immediately  adjacent  peritoneal  surfaces. 

The  abscess  in  these  cases  should  be  opened  and  drained,  the  ap- 
pendix being  removed  at  the  same  time  or  left,  according  to  the  cir- 
cumstance of  each  individual  case. 

During  the  opening  of  the  abscess  and  the  removal  of  the  ap- 
pendix care  should  be  exercised  not  to  break  through  the  barrier  of 
adhesions,  which  are  the  result  of  nature's  effort  to  protect  the  general 
peritoneal  cavity  from  infection. 


350  ABDOMEN  AND  BACK. 

The  location  of  the  abscess  differs  in  different  cases:  it  may  be 
located  anterior  to  the  caecum  within  a  mass  of  matted  guts  and  may 
be  opened  as  soon  as  the  incision  in  the  abdominal  wall  is  carried 
through  the  parietal  peritoneum.  The  abscess  may  be  located  behind 
and  to  the  outer  or  right  side  of  the  caecum,  reaching  upward  toward 
the  kidney  and  liver  or  downward  into  the  pelvis,  or  it  may  be  located 
to  the  inner  or  left  side  of  the  caecum,  or  it  may  lie  almost  entirely 
within  the  pelvis  and  cause  symptoms  due  to  pressure  upon  the  blad- 
der. Occasionally  there  is  more  than  one  collection,  and  care  should 
be  exercised  that  such  a  condition  does  not  escape  our  attention  at  the 
time  of  the  operation. 

The  Incision. — The  simple  incision  described  above,  cutting 
through  the  various  layers,  is  usually  employed.  It  should  be,  as  a 
rule,  about  four  inches  long,  and  may  be  increased  if  necessary  to 
allow  proper  work.  The  position  of  the  incision  may  be  somewhat 
changed  from  that  described  above  in  order  to  better  expose  the  tu- 
mor ;  thus  it  may  be  placed  farther  away  from  the  iliac  spine — nearer 
the  middle  line,  or  lower  down,  nearer  Poupart's  ligament  if  the 
position  of  the  tumor  should  indicate. 

Some  surgeons  use  the  McBurney  gridiron  incision  for  abscess 
cases  as  well  as  for  the  simple  appendicectomies. 

The  incision  is  carried  through  the  abdominal  wall,  layer  by 
layer,  until  the  peritoneum  is  reached,  and  then  after  the  hemor- 
rhage has  been  controlled  the  peritoneum  is  incised  carefully  in  order 
to  avoid  wounding  the  underlying  gut,  which  may  be  adherent  to  the 
parietal  peritoneum.  This  is  best  done  by  seizing  the  peritoneum 
with  two  mouse-toothed  forceps,  raising  it  up  and  cutting  between 
them. 

Having  incised  the  parietal  peritoneum,  we  may  find  ourselves 
at  once  within  the  abscess  cavity.  In  such  cases  the  abscess  is  found 
to  be  located  in  front  of  the  caecum.  When  this  condition  exists. 
we  may  often  note,  in  making  the  incision  through  the  abdominal 
wall,  that  the  deeper  layers — subperitoneal  tissue,  etc. — are  oedem- 
atous  and  infiltrated. 

In  most  cases,  however,  after  the  parietal  peritoneum  has  been 
incised,  we  come  down  upon  a  mass,  consisting  of  the  caecum  and 
small  intestine  adherent  and  matted  together,  and  within  this  the 
appendix  and  abscess  are  inclosed.  This  mass  may  be  still  further 
adherent  to  tbe  overlying  parietal  peritoneum,  which  lines  the  poste- 
rior surface  of  the  anterior  abdominal  wall,  in  which  case  the  general 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.      351 

peritoneal  cavity  is  excluded  from  the  likelihood  of  infection  from 
the  field  of  operation;  on  the  other  hand,  this  adhesion  between  the 
mass  of  matted  intestine  and  the  immediately  adjoining  parietal 
peritoneum  may  be  absent;  so  that,  when  the  fingers  are  introduced 
into  the  abdominal  cavity  through  the  incision,  they  may  be  passed 
freely  in  all  directions,  between  the  matted  mass  within  which  the 
abscess  is  located  and  the  overlying  parietal  peritoneum:  inward 
toward  the  umbilicus,  upward  toward  the  liver,  and  downward  into 
the  pelvis. 

Having  exposed  the  mass  within  which  the  abscess  and  appendix 
are  inclosed,  we  are  ready  to  evacuate  the  abscess.  Before  doing  this, 
however,  the  parts  should  be  properly  protected  by  gauze  pads  placed 
around  and  into  the  incision  in  the  abdomen,  and,  if  the  condition 
exists  as  described  above, — i.e.,  if  no  adhesions  have  been  formed 
between  the  mass  of  intestine  which  incloses  the  appendix,  etc.,  and 
the  parietal  peritoneum, — the  pads  should  also  be  tucked  into  this 
space  (between  the  matted  mass  and  the  anterior  abdominal  wall), 
in  order  to  block  it  off,  so  that  when  the  abscess  is  opened  the  entrance 
of  pus  into  the  general  peritoneal  cavity  will  be  prevented.  Later, 
after  the  abscess  has  been  evacuated,  etc.,  these  pads  may  be  removed 
and  replaced  by  fresh  sterile  pads  or  strips  of  gauze,  which  are 
allowed  to  remain,  with  their  ends  protruding  from  the  wound,  in 
order  to  obstruct  this  space  and  to  promote  the  formation  of  protect- 
ing adhesions. 

The  abdominal  incision  is  held  open  with  retractors  and  search 
made  for  the  abscess.  The  appendix  is  not  to  be  seen,  being  adherent 
and  buried  within  the  mass  of  matted  guts.  We  can  locate  the  point 
where  the  appendix  comes  off  from  the  caecum  by  following  down 
along  the  course  of  the  longitudinal  striae  and  gently,  with  the  fingers, 
working  between  the  adhesions  until  the  abscess  is  reached.    ■ 

As  the  abscess  is  opened  the  patient  may  be  turned  on  the  right 
side  to  facilitate  the  escape  of  the  pus,  which  is  swabbed  away  as  fast 
as  it  escapes.  The  abscess  cavity  may  be  gently  flushed  with  peroxide 
of  hydrogen,  which  may  be  preceded  and  followed  by  irrigation  with 
saline  solution. 

If  the  suppurative  process  involves  the  connective  tissue  behind 
the  colon,  reaching  up  toward  the  kidney,  the  question  of  a  counter- 
opening  in  the  loin  should  be  considered. 

After  the  pus  has  been  evacuated  and  the  abscess  cavity  sterilized 
the  attempt  to  remove  the  appendix  may  be  made.     The  operator 


352  ABDOMEN  AND  BACK. 

should  be  patient  and  gentle  in  his  search  for  the  appendix  and  in  the 
manipulation  that  is  necessary  to  free  it  sufficiently  to  permit  of  its 
excision.  Too  much  force,  especially  in  the  hands  of  inexperienced 
operators,  should  not  be  used  in  this  effort  to  free  the  appendix,  and 
one  may  wisely  in  many  cases  terminate  the  operation  at  this  stage, 
being  content  with  packing  the  abscess  cavity  and  leaving  the  ap- 
pendix to  take  care  of  itself,  or  to  be  removed  later,  after  suppuration 
has  ceased,  thus  giving  the  patient  the  best  chance  for  relief  from 
his  immediate  danger. 

There  is  no  question  as  to  the  desirability  of  removing  the  ap- 
pendix at  the  time  that  the  abscess  is  opened  if  the  conditions  permit, 
and  one  should  make  an  earnest  effort  to  accomplish  this.  If  the 
appendix  lies  to  the  inner  side  of  the  caecum,  there  is  probably  more 
danger  in  attempting  to  remove  it  than  if  it  is  located  to  the  outer 
side  or  below.  The  manipulations  required  to  detach  the  appendix 
where  an  abscess  has  been  present  may  cause  a  breaking  through  of 
the  adhesions  and  may  be  followed  by  peritonitis,  under  which  cir- 
cumstances the  patient's  chance  of  recovery  is  greatly  diminished.  On 
the  other  hand,  to  leave  the  diseased  appendix  in  the  wound  subjects 
the  patient  to  the  liability  of  a  faecal  fistula,  and — of  more  conse- 
quence than  this — to  a  subsequent  attack  of  appendicitis,  which  may 
be  fatal. 

At  times,  after  the  pus  has  been  evacuated,  the  appendix  is  found 
to  be  fairly  accessible,  and  may  be  felt  or  seen  in  the  abscess  cavity; 
so  that,  by  farther  separating  the  adhesions  with  the  fingers  and  with 
the  introduction  of  deep  retractors,  it  may  be  reached  and  removed. 
It  usually  suffices  to  simply  tie  a  catgut  ligature  around  the  appendix 
close  to  its  root — say,  one-half  inch  distant  from  the  caecum — and 
amputate  it  with  the  scissors.  The  stump,  which  is  steadied  with  the 
ligature,  left  long  for  this  purpose,  may  then  be  sterilized  with  pure 
carbolic  acid  or  the  Paquelin.  If  conditions  permit,  instead  of  treat- 
ing the  stump  in  this  simple  manner  it  may  be  inverted  into  the  caecum, 
as  described  above. 

For  drainage  the  most  satisfactory  material  is  iodoform  gauze, 
which  may  be  loosely  packed  in  the  abscess  cavity  or  else  made  into 
separate  bundles  inclosed  in  perforated  casings  of  oil-silk  or  gutta- 
percha tissue ;  in  addition  to  the  iodoform  gauze  it  is  often  advisable 
to  use  one  or  more  glass  or  rubber  tubes  perforated  on  the  sides,  espe- 
cially if  the  abscess  cavity  reaches  down  into  the  pelvis.  Some  sur- 
geons use  lamp-wick  instead  of  gauze  for  drainage. 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  353 

The  wound  in  the  abdomen  should  be  closed  in  part  with  two  or 
three  silk-worm  sutures  which  include  all  the  layers,  especially  the 
parietal  peritoneum,  and  which  are  introduced  with  a  large  curved 
surgeon's  needle.  Several  similar  sutures  may  also  be  introduced 
through  the  edges  of  that  part  of  the  wound  which  is  to  be  left  open, 
but  these  are  left  untied  until  after  the  suppuration  has  ceased  and 
the  drains  have  been  removed. 

Operations  for  Appendicitis  Accompanied  by  Progressive  or  Gen- 
eral Peritonitis  or  Peritoneal  Infection  due  to  perforation  or  slough- 
ing of  the  appendix  before  adhesions  have  been  formed  or  to  rupture 
or  leakage  of  an  appendicular  abscess  after  adhesions  have  been 
formed.  In  these  cases  the  appendix  should  be  removed  and  an  at- 
tempt made  to  prevent  or  check  the  general  peritoneal  infection. 

The  incision  should  be  sufficiently  long — four  to  six  inches;  if 
a  tumor  is  or  has  been  present  in  the  right  iliac  region  it  is  probably 
best  to  place  the  incision  in  the  right  semilunar  line,  reaching  down 
nearly  to  Pouparfs  ligament.  The  incision  in  other  cases  may  be 
better  placed  in  the  middle  line  of  the  abdomen  between  the  umbilicus 
and  the  symplrysis  pubis,  especially  if  previously  there  has  been  no 
tumor  in  the  right  iliac  fossa  and  the  onset  has  been  sudden  or  in 
cases  where  the  diagnosis  is  somewhat  in  doubt  and  signs  of  a  general 
peritonitis  or  peritoneal  infection  are  present. 

After  the  abdomen  has  been  opened  the  appendix  is  at  once  sought 
and  removed.  The  fluids  in  the  immediate  neighborhood  of  the  ap- 
pendix are  sponged  away,  and  the  whole  abdominal  cavity  and  intestine 
thoroughly  flushed  with  normal  salt  solution.  The  pelvis,  where  fluids 
are  especially  apt  to  collect,  should  be  cleared  and  flushed.  This  flush- 
ing should  be  thorough,  using  quarts  of  water  poured  from  a  pitcher 
or  conducted  into  the  abdomen  through  a  thick  glass  tube.  This 
washing  should  be  done,  if  possible,  without  removing  the  intestines 
from  the  abdominal  cavity,  as  this  adds  greatly  to  the  shock,  and  there 
may  be  some  difficulty  in  replacing  them.  One  may  follow  the  saline 
irrigation  with  peroxide  of  hydrogen,  this  in  turn  being  followed  up 
by  a  final  washing  with  saline  solution. 

If  the  intestine  is  coated  with  flaky  exudate  and  matted  with 
fresh  adhesions,  it  may  be  advisable  to  break  these  up  with  the  fingers 
in  order  to  make  the  flushing  satisfactory  and  thorough. 

A  glass  or  rubber  drainage  tube  with  a  gauze  strip  passed  through 
it  may  be  introduced  into  the  abdomen,  reaching  well  down  into  the 
pelvis,  and  strips  of  iodoform  gauze  introduced  into  the  abdomen 


354  ABDOMEN  AND  BACK. 

down  into  the  region  of  the  appendix  stump.  The  incision  in  the 
abdomen  is  closed  in  part  with  interrupted  sutures  of  silk-worm  gut 
which  pass  through  all  the  layers  of  the  abdominal  wall,  including  the 
parietal  peritoneum. 

Appendicostomy.  —  The  establishment  of  a  fistulous  opening 
through  the  appendix  into  the  caecum. 

This  plan  of  utilizing  the  appendix  was  suggested  by  Wier  for 
the  purpose  of  introducing  medicated  fluids,  solutions  of  nitrate  of 
silver,  etc.,  into  the  bowel  in  the  treatment  of  inflammatory  disease 
of  the  large  intestine,  ulcers,  etc. 

The  appendix  is  reached  in  the  usual  way  through  the  McBurney 
incision.  It  is  drawn  up  into  the  incision  and  secured  there  by  sev- 
eral catgut  sutures  which  fix  its  mesentery  to  the  edge  of  the  wound. 
The  tip  of  the  appendix  is  amputated  later  and  a  soft-rubber  tube 
introduced  through  it  into  the  caecum. 

According  to  Gibson,  a  fistula  may  be  made  in  the  caecum  for  the 
purpose  of  directly  medicating  the  colon.  The  procedure  of  Kader 
or  Witzel,  as  used  in  gastrostomy,  may  be  employed  for  this  purpose. 
This  plan  would  be  especially  servicable  in  cases  where  the  appendix 
is  not  available. 

THE  LIVER  AND  GALL=BLADDER. 

The  Surgical  Anatomy  of  the  Liver. — The  liver  is  a  solid  gland- 
ular organ  almost  completely  invested  by  the  peritoneum,  suspended 
in  the  upper  right  portion  of  the  abdomen  (right  hypochondrium) 
and  extending  beyond  the  middle  line  into  the  left  side  (left  hypo- 
chondrium). It  is  situated  under  cover  of  and  protected  by  the  ribs, 
except  in  the  epigastric  region.  Behind  and  toward  the  right  the 
liver  is  thick,  gradually  becoming  thin  toward  the  front  and  left. 
From  side  to  side  it  measures  eleven  inches;  from  before  backward, 
eight  inches;  and  its  posterior  border  has  a  thickness  of  two  and 
one-half  inches. 

Above,  the  diaphragm  separates  the  liver  from  the  pleura  and 
pericardium;  below  it  are  the  gall-bladder,  hepatic  flexure  of  the 
colon,  the  first  part  of  the  duodenum,  the  pylorus  and  stomach  (which 
it  overlaps),  and  the  right  kidney  and  suprarenal  capsule. 

The  superior  surface  of  the  liver  looks  forward  as  well  as  upward, 
and  is  in  relation  with  the  diaphragm  and  with  the  ribs  and  costal 
cartilages  from  the  fifth  or  sixth  to  the  tenth.  The  lower  limit  of  this 
surface  corresponds  to  the  free  border  of  the  ribs  (costal  cartilages). 


SURGICAL  ANATOMY  OF  THE  LIVER.  355 

This  upper  surface  of  the  liver  is  smooth,  and  presents  a  fold  of 
peritoneum  running  from  the  anterior  border  backward,  the  suspen- 
sory ligament.  This  serves  to  suspend  the  liver  to  the  diaphragm,  and 
is  the  continuation  of  the  falciform  fold  of  peritoneum,  which  is 
thrown  around  the  round  ligament  from  the  anterior  abdominal  wall 
and  which  extends  from  the  umbilicus  to  the  anterior  edge  of  the 
liver.  The  suspensory  ligament  divides  the  upper  surface  of  the 
liver  into  the  larger  right  lobe  and  the  smaller  left  lobe;  the  latter 
overlaps  the  stomach  and  reaches  to  the  left  beyond  the  middle  line. 
Toward  the  posterior  border  of  the  liver  the  folds  of  the  suspensory 
ligament  spread  out  right  and  left,  and,  still  passing  between  the 
liver  and  the  diaphragm,  form  the  anterior  layer  of  the  coronary 
ligament. 

The  posterior  border  of  the  liver,  really  a  surface,  is  thick,  grad- 
ually becoming  thin  toward  the  left,  and  is  not  covered  by  peritoneum ; 
the  peritoneum  which  covers  the  upper  surface  of  the  liver  upon 
reaching  its  posterior  border  is  reflected  upward  to  the  diaphragm 
as  the  anterior  layer  of  the  coronary  ligament,  and  that  which  covers 
the  under  surface  upon  reaching  the  posterior  border  of  the  liver  is 
reflected  on  to  the  posterior  abdominal  wall  (diaphragm),  forming 
the  posterior  layer  of  the  coronary  ligament.  The  coronary  ligament, 
at  either  end,  forms  the  right  and  left  lateral  ligaments  of  the  liver. 
The  posterior  border  of  the  liver,  to  the  left  of  the  middle  line,  pre- 
sents a  notch  which  corresponds  to  the  oesophagus  and  which  marks 
the  division  of  the  liver  into  its  right  and  left  lobes.  The  posterior 
border  of  the  liver  is  in  relation  with  the  diaphragm  and  lower  ribs, 
with  the  vertebral  column,  tenth  and  eleventh  dorsal,  the  aorta,  vena 
cava  inferior,  etc.  The  oesophagus  is  received  in  the  notch'  above 
mentioned. 

The  anterior  border  is  thin  and  in  many  patients  may  be  pal- 
pated through  the  abdominal  wall.  It  reaches  just  below  the  free 
border  of  the  ribs  (costal  cartilages),  and  corresponds  to  a  line  drawn 
from  the  tip  of  the  right  tenth  to  the  tip  of  the  left  eighth  costal 
cartilage,  where  this  joins  the  cartilage  of  the  seventh. 

The  under  surface  of  the  liver  is  irregular  and  marked  by  grooves 
and  impressions  for  the  colon,  gall-bladder,  kidney,  etc.,  and  is  cov- 
ered by  the  peritoneum,  which  is  reflected  downward  at  the  transverse 
fissure,  as  the  lesser  omentum,  as  far  as  the  lesser  curvature  of  the 
stomach,  where  its  folds  separate  to  include  the  stomach  between 
them. 


356  ABDOMEN  AND  BACK. 

Besides  the  right  and  left  lobes,  the  under  surface  of  the  liver 
presents  three  smaller  lobes:  the  quadrate,  caudate,  and  the  lobus 
Spigelii.  The  large  right  lobe  is  marked  by  the  transverse  fissure, 
which  passes  from  right  to  left  and  is  situated  rather  more  than 
half-way  back  from  the  anterior  border. 

At  this  fissure,  the  vessels,  ducts,  lymphatics,  and  nerves  pass 
in  and  out  of  the  liver.  These  structures  descend  in  the  right  free 
border  of  the  lesser  omentum,  between  its  two  folds,  the  common 
bile-duct  to  the  right,  the  hepatic  artery  to  the  left,  and  the  portal 
vein  between  and  behind  these  two.  The  hepatic  duct,  which  is 
formed  by  the  junction  of  the  right  and  left  bile-ducts,  emerges  from 
the  right  end  of  the  transverse  fissure  and  descends  between  the 
folds  of  the  lesser  omentum,  where  it  is  joined  by  the  cystic  duct 
to  form  the  common  bile-duct,  ductus  choledochus. 

If  we  examine  the  under  surface  of  the  liver  as  this  organ  lies 
in  its  normal  position  in  the  abdomen,  through  a  vertical  incision 
made  in  the  abdomen  from  the  tip  of  the  ninth  costal  cartilage,  we 
note,  in  sweeping  across  the  surface  from  right  to  left,  two  well- 
marked  grooves,  or  depressions,  into  which  the  finger  sinks;  the 
first,  that  toward  the  right,  corresponding  to  the  tip  of  the  ninth 
costal  cartilage,  lodges  the  gall-bladder ;  the  second,  nearer  the  middle 
line,  corresponds  to  the  round  ligament  (fcetal  umbilical  vein). 

The  Surgical  Anatomy  of  the  Gall-bladder  and  Bile-ducts. — The 
gall-bladder  is  a  pear-shaped,  hollow-receptacle.  Its  wall  is  fairly 
thick  and  is  composed  of  muscle  and  mucous  membrane.  The  serous 
coat  (peritoneum)  invests  the  under  surface  of  the  body  and  all  of 
the  fundus  of  this  organ,  binding  it  to  the  under  surface  of  the  liver. 
The  gall-bladder  lies  in  direct  relation  with  the  under  surface  of  the 
liver,  in  the  fossa  of  the  gall-bladder,  the  apposed  surfaces  of  the  gall- 
bladder and  liver  being  joined  to  each  other  by  loose  connective  tissue. 

The  fundus  of  the  gall-bladder  is  directed  downward,  forward, 
and  to  the  right,  usually  appearing  below  the  anterior  thin  edge  of 
the  liver,  opposite  the  tip  of  the  ninth  costal  cartilage.  Sometimes 
it  does  not  reach  quite  as  far  as  the  anterior  edge  of  the  liver,  and 
is  then  concealed  underneath  the  liver.  The  edge  of  the  liver,  corre- 
sponding to  the  fundus  of  the  gall-bladder,  is  sometimes  marked  by 
a  slight  notch. 

The  gall-bladder  is  three  to  four  inches  long  and  has  a  capacity 
of  about  one  and  one-half  ounces.  The  fundus  rests  upon  the  trans- 
verse colon,  and  the  neck,  the  posterior  narrow  part,  upon  the  first 


SURGICAL  ANATOMY  OF  THE  GALL-BLADDER.  357 

part  of  the  duodenum.  To  the  outer  side  of  the  gall-bladder — i.e., 
to  the  right — is  the  hepatic  flexure  of  the  colon;  to  the  left  of  the 
gall-bladder  is  the  pyloric  end  of  the  stomach.  The  neck  of  the  gall- 
bladder is  bent  upon  itself  before  being  continued  into  the  cystic 
duct.  The  cystic  duct  is  about  one-twelfth  inch  in  diameter  and  one 
or  two  inches  long.  Its  lumen  has  an  irregular,  spiral,  twisted  shape, 
which  makes  difficult  or  impossible  the  passage  of  a  probe  through 
it.  It  curves  downward  and  near  the  first  part  of  the  duodenum,  be- 
tween the  folds  of  the  lesser  omentum,  joins  with  the  hepatic  duct 
to  form  the  common  bile-duct. 

The  hepatic  duct  is  one-sixth  inch  in  diameter  and  two  inches 
long;  it  is  formed  by  the  junction  of  the  bile-ducts  from  the  right 
and  left  lobes  of  the  liver. 

The  common  bile-duct,  ductus  communis  choledochus,  varies 
in  length:  it  is  usually  three  inches  long  and  one-fourth  inch  in 
diameter;  it  continues  the  course  of  the  hepatic  duct,  descending 
between  the  folds  of  the  lesser  omentum,  lying  near  its  right  free 
edge — the  ligamentum  hepatico-duodenale.  In  this  situation  it  lies 
in  front  of  the  portal  vein  with  the  hepatic  artery  on  its  left  side; 
continuing  downward  it  passes  behind  the  first  part  of  the  duodenum, 
and  finally  behind  and  to  the  inner  side  of  the  second  part  of  duo- 
denum, between  it  and  the  head  of  the  pancreas.  The  upper  part  of 
the  common  duct  is  known  as  the  supraduodenal  portion  and  is  rather 
wider  than  the  lower  part,  which  is  known  as  the  retroduodenal  por- 
tion. The  lower  part  of  the  common  duct  is  imbedded  in  and  sur- 
rounded by  the  substance  of  the  pancreas.  Pathological  processes 
affecting  the  head  of  the  pancreas,  chronic  pancreatitis,  tumors,  etc., 
might  cause  obstructive  jaundice  by  compressing  the  common  duct. 
The  common  duct  perforates  the  wall  of  the  second  part  of  the  duo- 
denum upon  its  inner  side,  running  very  obliquely  in  the  wall  of  this 
part  of  the  gut  for  a  distance  of  from  one-half  to  three-fourths  inch. 
The  orifice  of  the  duct  upon  the  inner  surface  of  the  gut  is  marked 
by  a  papilla,  which,  as  a  rule,  is  readily  recognizable  by  the  sense  of 
touch  and  is  situated  from  three  to  four  inches  below  the  pylorus. 
The  orifice  or  mouth  of  the  common  duct  is  very  small,  permitting 
the  introduction  of  only  a  fine  probe,  2  mm.  in  diameter,  so  that  a 
stone  that  has  succeeded  in  traversing  the  whole  length  of  the  common 
duct  may  become  impacted  at  the  orifice.  Just  above  its  orifice  the 
common  duct  is  dilated,  pouched,  and  this  dilated  portion  is  known 
as  the  ampulla  of  Vater. 


358 


ABDOMEN  AND  BACK. 


Usually  the  pancreatic  duct  terminates  in  the  ampulla  of  Vater. 
Under  these  conditions  the  pancreatic  duct  and  the  common  bile-duct 
have  the  same  common  opening  into  the  duodenum.  Less  commonly 
the  pancreatic  duct  opens  into  the  duodenum,  not  through  the  am- 
pulla of  Vater,  but  independently,  through  a  separate  orifice  upon 
the  summit  of  the  papilla  that  marks  the  orifice  of  the  common  bile- 
duct. 


Fig.    159. — B,    bile-ducts;    C,   cystic   duct;    CB,   common    duct;    OB,    gall- 
bladder;  H,  hepatic  duct;   P,   pancreatic   duct. 


Attention  has  been  directed  by  Morison  to  the  space  in  the 
upper  part  of  the  abdomen  behind  the  liver,  into  which  the  gall- 
bladder presents.  It  is  bounded  above  and  anteriorly  by  the  right 
lobe  of  the  liver;  below  by  the  upper  or  ascending  layer  of  the  trans- 
verse mesocolon;  externally  by  the  abdominal  parietes  covered  by 
the  parietal  peritoneum;  posteriorly  by  the  layer  of  the  transverse 
mesocolon  which  covers  the  upper  part  of  the  right  kidney  and  ascends 
upon  the  posterior  abdominal  wall.  Internally,  the  space  is  bounded 
by  the  peritoneum,  which  is  reflected  over  the  bodies  of  the  vertebrae, 


OPERATIONS  UPON  THE  LIVER.  359 

aorta,  etc.  From  this  space,  following  down  along  the  gall-bladder 
and  cystic  duct,  one  can  pass  the  fingers,  behind  the  common  duct,  etc., 
through  the  foramen  of  Winslow,  into  the  lesser  cavity  of  the  perito- 
neum,— i.e.,  into  the  peritoneal  space  behind  the  stomach. 

OPERATIONS  UPON  THE  LIVER. 

Hepatotomy. — Incision  of  the  liver  for  abscess,  hydatid  cyst,  etc. 

The  incision,  when  the  disease  involves  the  right  lobe,  is  placed 
along  the  outer  border  of  the  rectus  muscle,  extending  from  the  tip 
of  the  ninth  costal  cartilage  downward  for  a  distance  of  from  three 
to  five  inches. 

At  times  it  may  be  desirable  to  place  the  incision  elsewhere  in 
order  that  it  may  correspond  with  the  prominence  of  the  tumor; 
for  example,  if  the  abscess  is  located  in  the  left  lobe  of  the  liver, 
then  the  incision  is  better  placed  in  the  middle  line,  linea  alba.  The 
incision  is  carried  through  the  integument,  fascia,  etc.,  down  to  the 
peritoneum,  and  after  the  hemorrhage  has  been  controlled  the  parietal 
peritoneum  is  incised  between  two  mouse-tooth  forceps.  We  may 
find  the  tumor  adherent  to  the  parietal  peritoneum,  and  in  this  case, 
after  aspirating  to  discover  the  nature  of  its  contents,  we  may  incise 
the  tumor  and  evacuate.  The  finger  is  then  introduced  into  the  abscess 
cavity  to  explore  and  break  up  septa,  etc.  The  cavity  is  finally  packed 
with  iodoform  gauze.  Under  these  circumstances  the  operation  is 
very  simple  and  there  is  no  danger  whatever  of  infecting  the  general 
peritoneal  cavity. 

If,  however,  after  incising  the  peritoneum  we  find  that  the  tumor 
is  not  adherent  to  the  parietal  peritoneum, — i.e.,  if  we  can  pass  the 
hand  freely  between  the  tumor  and  the  parietal  peritoneum, — we  must 
take  measures  to  prevent  infection  of  the  general  peritoneal  cavity 
while  the  contents  of  the  cavity  are  being  evacuated,  and  to  accomplish 
this  we  do  the  operation  in  two  sittings. 

First,  having  exposed  the  tumor,  the  parietal  peritoneum  is 
united  to  the  edges  of  the  skin  with  two  or  three  catgut  sutures  on 
either  side,  and  then  strips  of  gauze  are  packed  into  the  wound  be- 
tween the  tumor  and  parietal  peritoneum  for  the  purpose  of  shutting 
off  the  general  peritoneal  cavity  in  case  of  leakage  and  to  stimulate 
the  formation  of  adhesions  between  the  tumor  and  the  parietal  peri- 
toneum. One  may  then  aspirate  with  a  fine  needle  in  order  to  discover 
the  nature  of  the  contents  and  to  relieve  the  tension  somewhat. 


360  ABDOMEN  AND  BACK. 

The  incision  in  the  abdomen  is  left  open  and  packed  down  to 
the  surface  of  the  tumor  or  the  incision  may  be  closed  in  part  by 
one  or  two  sutures  of  silk-worm  gut  which  pass  through  all  the  layers 
of  the  abdomen,  including  the  parietal  peritoneum. 

After  an  interval  of  several  days,  when  adhesions  have  formed, 
etc.,  the  tumor,  abscess,  or  hydatid  cyst  may  be  incised  either  with 
the  Paquelin  cautery  or  the  knife,  and  drained. 

Hepatectomy  (Excision  of  Diseased  Portion  of  the  Liver). — Por- 
tions of  the  liver  have,  in  some  instances,  been  excised  when  involved 
primarily  or  by  extension  from  growths  of  the  gall-bladder  and  ducts 
either  by  means  of  the  Paquelin  cautery  or  by  blunt  dissection  (enu- 
cleation) with  the  finger.  Large  individual  vessels  may  be  clamped 
and  tied  as  they  are  met  with  during  the  operation.  The  space  which 
remains  in  the  liver  after  the  removal  of  the  diseased  part  may  be 
closed  by  approximation  of  its  edges  with  sutures  of  catgut;  but  if 
there  is  much  tension  these  may  tear  through. 

Injuries  of  the  Liver. — The  liver  may  be  lacerated  by  blows  upon 
the  abdomen,  by  fractured  ribs,  or  by  bodies  causing  penetrating 
wounds.  These  injuries  may  be  accompanied  by  free  hemorrhage. 
On  account  of  the  solid  structure  of  the  liver  large  venous  channels 
cannot  collapse,  and  thus  hemorrhage  is  favored.  Hemorrhage  may 
be  controlled  by  the  cautery  or  by  packing,  or  by  packing  combined 
with  suture. 

Omentopexy  (Talma). — This  operation  consists  in  attaching  the 
omentum  to  the  parietal  peritoneum.  It  is  performed  for  the  purpose 
of  establishing  compensatory  anastomosis  between  the  portal  and  gen- 
eral venous  systems.  In  addition  to  fixing  the  omentum  to  the  parietal 
peritoneum  it  is  desirable  at  the  same  time  to  induce  adhesions  between 
the  liver  and  spleen  and  the  corresponding  peritoneal  surface  opposite 
these  organs. 

The  operation  is  recommended  for  the  relief  and  cure  of  ascites 
due  to  cirrhosis  of  the  liver,  and  if  one  may  judge  from  the  limited 
number  of  cases  that  have  been  reported  it  certainly  offers  a  prospect 
of  relief,  especially  if  undertaken  in  properly  selected  cases.  The 
operation  should  not  be  done  in  those  cases  where  the  pathological 
changes  in  the  liver  have  progressed  to  an  extreme  degree. 

Normally  the  portal  and  general  venous  systems  communicate 
through  small  branches  that  are  located  in  the  subperitoneal  connec- 
tive tissue  between  the  layers  of  the  hepatic  ligament;  these  connect 
branches  of  the  portal  vein  with  the  radicles  of  the  phrenic  vein  and 


OPERATIONS  UPON  THE  LIVER.  361 

azygos  major' veins.  A  large  branch  running  in  the  round  ligament 
from  the  liver  to  the  umbilicus  connects  the  left  branch  of  the  portal 
vein  with  the  epigastric  and  other  veins  in  the  abdominal  parietes; 
these  veins  frequently  become  prominent  in  cirrhosis  of  the  liver. 
The  coronary  veins  which  drain  the  stomach  communicate  with  both 
azygos  veins  through  the  oesophageal  plexus;  the  veins  of  the  oesoph- 
ageal plexus  may  be  found  varicosed  and  may  be  the  source  of  severe 
hemorrhage  in  cirrhosis  of  the  liver.  The  inferior  mesenteric  com- 
municates with  the  internal  iliac  through  the  inferior  and  middle 
hemorrhoidal  veins.  The  pancreatic  veins  communicate  with  retro- 
peritoneal venous  branches.  In  case  of  obstruction  of  the  portal  cir- 
culation caused  by  cirrhosis  of  the  liver  the  means  of  communication 
mentioned  above  are  not  sufficiently  ample  to  relieve  the  obstructed 
portal  system.  The  operation  of  omentopexy  is  resorted  to  with  the 
object  of  establishing  new  channels  of  communication  through  the 
venous  branches  that  are  formed  in  the  adhesions  between  the  attached 
omentum  and  liver  and  spleen  (portal  system)  and  the  peritoneum 
(general  venous  system).  It  may  be  observed  after  omentopexy  that 
the  superficial  veins  of  the  abdomen  and  about  the  umbilicus  become 
very  prominent  and  smaller  veins  that  are  usually  invisible  are  plainly 
to  be  seen. 

Incision  is  made  from  the  ensiform  process  to  the  umbilicus  in 
the  linea  alba  or  to  the  right  of  the  middle  line,  penetrating  between 
the  fibers  of  the  rectus  muscle.  When  the  abdomen  is  opened  the 
chief  bulk  of  the  fluid  escapes  and  the  rest  is  removed  with  gauze 
swabs.    In  this  manner  the  abdominal  cavity  is  emptied. 

The  hand  is  introduced  into  the  abdomen  and  the  parts  exam- 
ined, especially  the  liver  and  spleen.  The  upper  surface  of  the  liver, 
and  the  outer  surface  of  the  spleen  and  the  corresponding  portions  of 
the  parietal  peritoneum,  that  covering  the  diaphragm  opposite  the 
liver  and  that  of  the  abdominal  wall  opposite  the  spleen,  are  vigor- 
ously rubbed  with  a  rough  piece  of  gauze  until  there  is  a  slight  tend- 
ency to  oozing.  The  parietal  peritoneum  for  a  considerable  distance 
upon  either  side  of  the  abdominal  incision  is  treated  in  a  similar 
manner.  The  great  omentum  is  then  sutured  to  the  peritoneum  that 
lines  the  anterior  abdominal  wall  for  some  distance  upon  each  side 
of  the  incision.  The  attachment  of  the  omentum  to  the  anterior 
abdominal  wall  should  be  sufficiently  extensive  so  as  to  give  a  good, 
broad  area  for  adhesions  to  form.  Chromicized  catgut  should  be 
used  for  suture  material. 


362  ABDOMEN  AND  BACK. 

Some  surgeons  recommend  suturing  the  omentum  into  a  pocket 
made  for  the  purpose  between  the  parietal  peritoneum  and  the  ab- 
dominal muscles. 

The  abdominal  incision  is  closed  throughout,  the  peritoneum 
with  plain  catgut  and  the  other  layers  with  interrupted  sutures  of 
silk  or  silk-worm  gut. 

The  Question  of  Drainage. — Drainage  has  been  used  to  prevent 
reaccumulation  of  fluid  during  the  time  that  the  adhesions  are  form- 
ing, etc.,  and  for  this  purpose  it  would  be  of  great  advantage;  but, 
on  the  other  hand,  the  drainage  opens  the  way  to  fatal  peritoneal  infec- 
tion. The  other  plan,  which  is  probably  the  better  one  in  most  cases, 
is  to  omit  drainage  and  resort  to  tapping  after  the  operation,  as  often 
as  necessary  to  prevent  reaccumulation  of  fluid.  If  drainage  is  em- 
ployed a  glass  or  rubber  tube  may  be  introduced  into  the  abdomen 
through  a  small  incision  made  for  the  purpose  in  the  lower  part  of 
the  abdomen  in  the  middle  line. 

OPERATIONS  UPON  THE  GALL=BLADDER. 

Aspiration  of  the  Gall-bladder. — Drawing  off  the  contents  of  the 
gall-bladder,  usually  for  purposes  of  diagnosis.  This  operation  may 
be  resorted  to  in  order  to  determine  the  nature  of  a  tumor  which  can 
be  felt  through  the  abdominal  wall.  The  needle  is  introduced  over 
the  most  prominent  part  of  the  tumor,  usually  below  the  tip  of  the 
ninth  costal  cartilage,  and  some  of  the  contents  withdrawn.  ■  The 
needle  should  be  of  small  caliber. 

This  is  a  dangerous  procedure  and  one  to  be  condemned,  even 
if  the  needle  and  skin  are  made  aseptic,  because  some  of  the  contents 
is  very  apt  to  escape  through  the  puncture  in  the  wall  of  the  gall- 
bladder upon  withdrawing  the  needle,  especially  if  the  needle  used 
is  not  fine,  and  if  the  material  is  infectious  a  fatal  peritonitis  may 
be  thus  set  up. 

Cholecystotomy. — Incision  of  the  gall-bladder  for  the  purpose  of 
removing  stones.  The  incision  in  the  gall-bladder  is  closed  imme- 
diately after  stones,  etc.,  have  been  removed — the  "Ideal  Operation"  of 
Bernays.  The  operator  must  be  positive  that  the  mucous  membrane 
of  the  gall-bladder  is  healthy  and  that  the  bile-ducts — hepatic,  cystic, 
and  common — are  patent  before  proceeding  to  close  the  opening  in 
the  bladder. 

An  incision  is  made  which  reaches  from  the  tip  of  the  ninth 
costal  cartilage  vertically  downward,  in  the  linea  semilunaris,  along 


OPERATIONS  UPON  THE  GALL-BLADDER.  363 

the  outer  side  of  the  rectus  or  just  exposing  the  outer  edge  of  this 
muscle,  three  to  four  inches  long.  Having  cut  through  the  several 
layers  of  the  wall  of  the  abdomen,  the  parietal  peritoneum  is  ex- 
posed. Before  incising  the  peritoneum,  all  bleeding  points  in  the 
abdominal  wall  are  clamped.  The  parietal  peritoneum  is  then  caught 
up  with  two  mouse-tooth  forceps  and  snipped  between  these  with  the 
knife,  whereupon  the  finger  is  introduced  and  the  opening  enlarged 
with  the  scissors,  cutting  upon  the  finger  as  a  guide.  Instead  of  the 
vertical  an  oblique  incision  may  be  used,  one  finger's  breadth  distant 
from  and  parallel  with  the  free  border  of  the  ribs,  the  middle  of  the 
incision  corresponding  to  the  tip  of  the  ninth  costal  cartilage.  This 
incision  is  usually  four  to  five  inches  long.  The  vertical  incision  is 
probably  the  preferable  one. 

After  the  parietal  peritoneum  has  been  incised  the  sharp  ante- 
rior edge  of  the  liver  is  seen  in  the  upper  part  of  the  incision  and 
the  transverse  colon  in  the  lower  part.  The  gall-bladder  may  also  be 
seen,  more  or  less  distended,  projecting  beneath  the  anterior  border 
of  the  liver,  or  it  may  be  small  and  concealed  beneath  the  edge  of  the 
liver.  Occasionally  in  order  to  bring  the  fundus  of  the  gall-bladder 
into  the  wound  it  may  be  necessary  to  draw  the  liver  well  upward  or 
to  incise  the  thin  layer  of  liver-tissue  that  overlies  the  fundus  of 
the  gall-bladder,  or  it  may  be  necessary,  with  the  finger,  to  break 
up  some  adhesions  that  bind  the  gall-bladder  to  the  neighboring  organs. 
If  stones  are  present  they  may,  in  many  cases,  be  felt  through  the  wall 
of  the  gall-bladder  without  incising  it. 

Before  opening  the  gall-bladder  the  hepatic,  cystic,  and  common 
ducts  should  be  examined  for  stones,  etc.  Occasionally  the  gall- 
bladder may  be  found  distended  to  such  a  degree  and  forms  such  a 
large  tumor  that  it  will  be  necessary  to  empty  it  with  the  aspirator 
before  a  satisfactory  examination  of  the  ducts  can  be  made.  The  com- 
mon duct  may  be  palpated  between  the  two  fingers  of  the  left  hand 
introduced  into  the  foramen  of  Winslow  and  the  thumb  opposed  ante- 
riorly. A  normal  common  duct  may  not  be  made  out  by  palpation, 
but  one  containing  a  stone  or  stones,  and  especially  if  it  is  dilated  and 
its  wall  thickened,  may  be  readily  recognized. 

After  the  examination  of  the  ducts,  etc.,  has  been  completed,  the 
fundus  of  the  gall-bladder  is  secured  with  two  silk  tractor  sutures, 
which  are  introduced  for  the  purpose  of  steadying  it;  these  sutures 
should  take  a  good,  broad  bite,  but  should  not  penetrate  through  the 
entire  thickness  of  the  bladder  wall.    Instead  of  using  tractor  sutures 


364  ABDOMEN  AND  BACK. 

the  fundus  of  the  bladder  may  be  seized  and  steadied  with  two  artery- 
forceps. 

The  gall-bladder  should  be  emptied,  as  nearly  completely  as  pos- 
sible, with  the  aspirator  before  it  is  incised.  Gauze  pads  are  tucked 
into  the  abdominal  incision  and  around  the  gall-bladder  in  order  to 
protect  the  peritoneal  cavity  against  leakage.  A  hollow  needle  of  large 
caliber  is  thrust  into  the  fundus  of  the  bladder  and  as  much  of  the 
fluid  contents  as  possible  drawn  off  with  the  aspirator.  The  organ 
is  then  held  up  and  steadied  with  the  tractor  sutures  or  forceps  and 
opened,  making  the  incision  in  its  fundus,  and  any  remaining  fluid 
contents  swabbed  out  with  gauze  wipes  on  holders.  Stones  that  are 
present  may  be  removed  with  a  scoop  or  forceps  and  the  finger  intro- 
duced in  order  to  explore  the  interior  of  the  organ.  Care  must  be 
exercised  not  to  overlook  stones  impacted  in  the  neck  of  the  gall- 
bladder or  in  the  cystic  duct.  They  can,  at  times,  be  forced  back 
into  the  bladder  and  removed.  If  the  cystic  duct  has  been  obstructed, 
as  soon  as  the  obstruction  is  relived  there  is  apt  to  be  a  copious  flow 
of  bile  from  the  cystic  duct  into  the  gall-bladder.  This  bile  should 
be  prevented  from  entering  the  peritoneal  cavity.  Although  normal 
bile  in  the  peritoneal  cavity  does  not  cause  a  septic  peritonitis,  still  its 
entrance  in  any  considerable  quantity  should  be  avoided. 

After  the  gall-bladder  has  been  thus  emptied  and  its  interior 
swabbed  out  dry  with  antiseptic  •  gauze  wipes,  it  may  be  temporarily 
tamponed  with  strips  of  gauze  and  the  bile-passages,  hepatic,  cystic, 
and  common  ducts,  again  carefully  examined  for  stone,  etc. 

It  has  been  suggested,  in  order  to  test  the  patency  of  the  ducts, 
to  introduce  a  gum  catheter  through  the  incision  in  the  gall-bladder 
into  the  cystic  duct  and  onward  through  this  into  the  common  duct. 
In  many  cases,  however,  owing  to  the  twisting  and  irregularity  of  the 
interior  of  the  cystic  duct,  the  catheter  may  catch  in  its  wall  and  fail 
to  pass  even  when  the  duct  is  unobstructed.  If  not  successful  with 
the  catheter,  Abbe  has  suggested  a  stream  of  water  introduced  into  the 
gall-bladder  under  pressure ;  if  it  flows  freely  it  indicates  that  the  ducts 
are  patent.  After  the  operator  has  satisfied  himself  that  the  ducts  are 
unobstructed  and  if  the  contents  of  the  gall-bladder  were  not  purulent 
he  may  withdraw  the  temporary  gauze  packing  from  the  bladder  and 
proceed  to  suture  the  opening  in  it  and  the  incision  in  the  abdomen. 
The  incision  in  the  gall-bladder  is  closed  with  a  double  row  of  sutures. 
The  first  row,  of  catgut,  includes  the  whole  thickness  of  the  wall  and 
serves  to  close  the  opening;  it  may  be  continuous  or  consist  of  several 


OPERATIONS  UPON  THE  GALL-BLADDER.  365 

interrupted  stitches.  This  first  line  of  suture  is  reinforced  by  a  second 
row  of  silk  Lembert  sutures,  which  should  include  only  the  serous  and 
muscular  coats  of  the  gall-bladder;  these  serve  to  bury  the  first  row 
and  bring  the  adjoining  serous  surfaces  into  accurate  apposition.  The 
incision  in  the  abdomen  is  closed  by  uniting,  first,  the  edges  of  the 
parietal  peritoneum  with  a  continuous  catgut  suture  and  then  the 
transversalis  fascia  and  muscle  (aponeurosis)  are  brought  together 
with  a  second  continuous  catgut  suture;  finally  the  edges  of  the  skin 
are  united  with  a  catgut  suture.  After  the  edges  of  the  peritoneum 
have  been  sutured,  the  other  layers — skin,  aponeurosis,  fascia,  etc. — 
may  be  approximated  with  several  interrupted  sutures  of  silk-worm 
gut,  each  suture  including  all  of  these  layers,  but  omitting  the  peri- 
toneum. 

Cholecystostomy. — The  establishment  of  a  fistulous  opening  in 
the  gall-bladder;  for  the  removal  of  calculi  and  in  order  to  drain  the 
gall-bladder  and  liver.  In  this  operation  the  opening  in  the  bladder 
is  not  closed,  but  is  left  open  in  order  to  provide  drainage,  etc.  This 
is  the  safest  and  simplest  of  all  operations  for  the  relief  of  cholelithia- 
sis. The  details  of  the  method  vary  according  to  the  condition  of  the 
gall-bladder:  whether  it  is  sufficiently  large  to  permit  of  its  being 
drawn  into  the  abdominal  incision  or  contracted,  shrunken,  to  such 
a  degree  that  it  cannot  be  brought  up  into  the  incision. 

Cholecystostomy  in  Cases  where  the  Gall-bladder  is  Un- 
CONTRACTED. — The  operation  may  be  performed  in  one  or  two  sittings. 

Cholecystostomy  in  a  Single  Sitting. — This  is  the  usual  method, 
the  gall-bladder  being  opened  and  stones  removed,  etc. — the  entire 
operation  completed  in  the  one  sitting. 

An  incision  as  described  in  the  preceding  operation,  either  ver- 
tical, passing  from  the  tip  of  the  ninth  costal  cartilage  downward, 
or  oblique,  parallel  with  the  free  border  of  the  ribs.  Probably  the 
vertical  incision  is  preferable  in  most  cases.  The  incision  may  be 
located  nearer  to  the  middle  line  if  the  presence  of  a  tumor  indicates, 
so  that  it  may  be  over  the  most  prominent  part  of  the  tumor. 

After  the  abdomen  has  been  opened,  the  gall-bladder  is  found 
more  or  less  distended  and  presenting  beneath  the  free  anterior  edge 
of  the  liver,  and  may  be  adherent  to  neighboring  parts — colon,  duo- 
denum, etc.  These  adhesions  should  be  gently  broken  down  by  the 
fingers  in  the  abdomen  and  then,  before  opening  the  gall-bladder,  the 
cystic,  hepatic,  and  common  bile-ducts  should  be  carefully  palpated 
for  impacted  calculi,  etc.    The  method  of  examining  the  common  duct 


366  ABDOMEN  AND  BACK. 

with  the  fingers  in  the  foramen  of  Winslow,  etc.,  has  been  explained 
in  the  description  of  the  preceding  operation. 

After  the  examination  of  the  bile-ducts  has  been  completed  the 
fundus  of  the  gall-bladder  is  secured  with  two  tractor  sutures  or 
artery  forceps  and  the  organ  aspirated  and  incised  in  just  the  same 
manner  as  described  in  the  operation  of  cholecystotomy.  The'  steps 
of  this  operation  are  similar  to  those  of  the  latter  operation,  chole- 
cystotomy, up  to  the  point  of  closing  the  incision  in  the  bladder.  In 
this  operation  the  incision  in  the  bladder  is  not  closed,  but  left  open 
and  stitched  in  the  abdominal  wound  for  drainage,  etc.  The  gall- 
bladder, after  it  has  been  evacuated  and  wiped  out  dry,  is  packed, 
temporarily,  with  strip  gauze,  to  prevent  leakage. 

Each  edge  of  the  parietal  peritoneum  is  fixed  to  the  deep  muscle 
and  transversalis  fascia  of  the  corresponding  margin  of  the  abdominal 
incision  with  two  interrupted  sutures  of  catgut,  or  silk  with  the  ends 
left  long,  and  we  are  then  ready  to  stitch  the  edges  of  the  opening  in 
the  gall-bladder  in  the  upper  part  of  the  abdominal  incision.  The 
edges  of  the  opening  in  the  gall-bladder  are  fixed  to  the  upper  part  of 
the  abdominal  incision  with  a  sufficient  number  of  interrupted  sutures. 
These  are  of  moderately  thick  black  silk,  placed  about  one-fourth  inch 
apart  and  their  ends  left  very  long  to  facilitate  their  removal  later. 
They  penetrate  the  entire  thickness  of  the  gall-bladder  wall,  uniting  it 
to  the  parietal  peritoneum,  transversalis  fascia,  and  deep  muscle  in 
the  margin  of  the  abdominal  incision.  These  stitches  should  not  in- 
clude the  aponeurosis  or  the  skin. 

The  lower  part  of  the  abdominal  incision  is  closed  with  several 
interrupted  silk  or  silk-worm  gut  sutures.  These  penetrate  all  the 
layers  of  the  abdominal  wall,  special  care  being  exercised  to  include  the 
parietal  peritoneum  in  each  stitch.  These  sutures  are  best  introduced 
before  those  that  fix  the  gall-bladder,  but  they  are  not  tied  until  after 
the  latter  have  all  been  inserted  and  tied. 

The  temporary  gauze  packing  is  removed  from  the  gall-bladder 
and  a  tube  with  a  moderately  large  lumen  introduced.  A  strip  of 
gauze  is  packed  loosely  into  the  wound  about  the  tube.  The  tube 
may  be  fixed  to  the  edge  of  the  skin  incision  with  a  silk  suture  to 
prevent  its  slipping  out. 

Cholecystostomy  in  Two  Sittings. — With  the  surgical  technique 
of  the  present  day  this  method  is  seldom  employed,  and  it  is  ques- 
tionable if  it  is  to  be  preferred  in  any  case  to  the  one  just  described 
which  accomplishes  the  entire  operation  in  a  single  sitting.     The 


Fig.  160 — Cholecystostorny.  Gall-bladder  has  been  incised  and  the  edges  of  the 
opening  fixed  to  the  edges  of  the  peritoneum  and  deep  muscle  in  the  abdominal  in- 
cision. Sutures  1  and  2  which  have  net  yet  been  tied,  secure  the  wall  of  the  gall-bladder 
above  and  below  just  beyond  opening  in  same.  Sutures  3,  4  and  5  are  for  the  purpose 
of  closing  abdominal  incision  in  part. 


OPERATIONS  UPON  THE  GALL-BLADDER.  367 

operation  might  be  indicated  in  some  exceptional  cases  for  the  removal 
of  stones  from  the  gall-bladder  where  the  symptoms  are  not  urgent. 
This  method  could  not  be  employed  if  the  gall-bladder  were  con- 
tracted or  very  thin  walled. 

A  vertical  incision,  about  four  inches  long  and  reaching  from 
the  tip  of  the  ninth  costal  cartilage,  is  made  in  the  abdominal  wall 
and  through  this  the  gall-bladder  is  exposed.  As  was  described  in  the 
preceding  operations,  the  bile-ducts — cystic,  hepatic,  common — should 
be  carefully  examined  for  impacted  calculi,  etc. 

The  edges  of  the  parietal  peritoneum  are  fixed  to  the  margins  of 
the  abdominal  incision  with  two  interrupted  catgut  sutures  on  each 
side;  these  join  the  edges  of  the  peritoneum  to  the  corresponding  edges 
of  the  transversalis  fascia  and  deep  muscle  layer.  Two  silk  tractor 
sutures,  which  do  not  penetrate  through  the  entire  thickness  of  its 
wall,  are  then  introduced  in  the  fundus  of  the  bladder  in  order  to 
steady  it. 

Four  moderately  thick  silk  sutures  (A,  B,  C,  and  D,  Fig  161) 
are  then  introduced  through  the  edges  of  the  abdominal  incision ;  two 
in  the  upper  part  of  the  incision  and  two  in  the  lower  part.  Each  of 
these  sutures  passes  through  all  of  the  layers  of  the  abdomen.  The 
two  middle  sutures,  marked  B  and  C  (Fig.  161)  pick  up  the  wall  of 
the  gall-bladder  in  their  course;  they  should  each  take  one  or  two 
good,  broad  bites  in  the  wall  of  the  gall-bladder,  but  should  not  pene- 
trate its  entire  thickness;  these  two  sutures  (B  and  C)  serve  par- 
tially to  fix  the  gall-bladder  in  the  abdominal  incision,  and  there  should 
be  a  space  of  from  one  and  one-half  to  two  inches  intervening  between 
them.  The  uppermost  and  lowermost  sutures  (marked  A  and  D), 
which  are  simply  for  the  purpose  of  closing  the  abdominal  incision 
for  part  of  its  length,  are  introduced  before  the  two  middle  sutures, 
which  pick  up  the  wall  of  the  gall-bladder,  but  they  should  not  be 
tied  until  after  the  two  middle  sutures  (B  and  C)  have  been  intro- 
duced. 

The  fundus  of  the  gall-bladder  is  still  further  united  to  the  edges 
of  the  abdominal  incision,  between  the  sutures  B  and  C,  with  several 
additional  sutures  on  either  side.  These  stitches  take  a  good,  broad 
bite  in  the  wall  of  the  gall-bladder  without  going  through  its  entire 
thickness,  and  in  the  edges  of  the  abdominal  incision  they  pierce  the 
peritoneum,  transversalis  fascia,  and  deep  muscle  layers  only — they 
do  not  include  the  aponeurosis  nor  the  skin.  These  accessory  sutures 
are  of  silk  with  their  ends  left  very  long,  and  are  best  introduced  with 


368 


ABDOMEN  AND  BACK. 


a  thin,  curved  surgeon's  needle;    they  are  more  readily  introduced 
before  the  sutures  B  and  C  have  been  tied. 

When  the  operation  has  been  completed  we  have  the  fundus  of  the 
unopened  gall-bladder  fixed  in  the  abdominal  incision,  which  is  left 
open  for  from  one  and  one-half  to  two  inches  of  its  length.  The  wound 
is  packed  loosely  with  gauze,  leaving  the  tractor  sutures  in  place,  and 


::-.  ■■.■■::■:■■  m'- 


V  ft 


Fig.  161.— Cholecystectomy.  Fundus  of  the  gall-bladder  drawn  into  the 
incision  and  fixed;  A,  D,  sutures  through  all  the  layers  of  the  abdominal 
•wall  that  serve  to  diminish  size  of  the  incision;  B,  C,  sutures  that  pass 
through  the  edges  of  the  incision  in  the  abdomen,  but  catch  up  the  wall  of 
the  gall-bladder  as  they  pass  across  from  one  edge  of  the  incision  to  the 
other. 

after  two  or  three  days  the  gall-bladder  is  opened  between  the  tractors 
with  the  knife  or  Paquelin  cautery  and  emptied  of  its  contents. 

Cholecystostomy  where  the  Gall-bladder  is  Contracted. 
— At  times  the  gall-bladder  is  found  so  shrunken,  contracted,  as  a 
result  of  chronic  or  recurring  inflammatory  action  that  it  is  impos- 
sible to  draw  it  up  into  the  abdominal  incision.  This  condition  is 
frequently  encountered  in  connection  with  chronic  stone  obstruction 
of  the  common  duct. 


OPERATIONS  UPON  THE  GALL-BLADDER.  369 

The  abdomen  is  opened  through  the  usual  longitudinal  incision 
commencing  at  the  tip  of  the  ninth  rib,  and  then  after  the  gall-bladder 
has  been  exposed,  but  before  incising  it,  the  bile-ducts — hepatic,  cys- 
tic, and  common — are  carefully  examined  by  palpation  with  the  fingers 
in  the  foramen  of  Winslow  as  already  described. 

After  this  examination  has  been  completed  and  after  protecting 
gauze  pads  have  been  properly  placed  to  protect  the  peritoneal  cavity, 
the  gall-bladder  is  opened,  emptied  of  its  contents,  stones  removed, 
etc.,  and  its  interior  swabbed  out  dry  with  antiseptic  gauze  wipes  on 
holders.  We  are  then  ready  to  complete  the  operation  by  arranging 
for  drainage  of  the  gall-bladder,  and  this  is  done  according  to  the  plan 
of  Poppert. 

A  rubber  catheter  is  introduced  into  the  gall-bladder  and  fixed 
in  the  lower  corner  of  the  incision  that  has  been  made  in  its  fundus 
with  a  silk  stitch.  The  stitch  penetrates  both  edges  of  the  incision 
in  the  gall-bladder  and  pierces  the  catheter  as  well,  so  that  when  it 
is  tied  it  draws  the  edges  of  the  incision  tightly  around  the  catheter 
and  at  the  same  time  secures  it  so  that  it  cannot  slip  out  of  the  gall- 
bladder. The  rest  of  the  incision  in  the  bladder  is  closed  with  a 
sufficient  number  of  interrupted  sutures.  These  sutures  are  of  silk 
and  may  be  penetrating,  piercing  the  entire  thickness  of  the  wall  of  the 
gall-bladder,  and  their  ends  left  long  so  as  to  facilitate  their  removal 
later,  or  they  may  be  non-penetrating  Lembert  sutures,  their  ends  cut 
short  and  allowed  to  remain  permanently.  Two  or  three  strips  of 
gauze  are  packed  into  the  abdomen  alongside  of  the  catheter  as  far  as 
the  suture  line  in  the  gall-bladder.  The  catheter  is  secured  to  the 
edge  of  the  abdominal  incision  with  a  single  silk  stitch  to  guard 
against  its  becoming  displaced.  The  entire  contents  of  the  gall- 
bladder escape  through  the  catheter  without  soiling  the  adjacent 
gauze  packing  or  the  dressings.  The  catheter  functionates  without 
leakage  for  from  ten  to  fourteen  days,  and  after  this  lapse  of  time 
sufficient  adhesions  have  been  formed  to  wall  off  the  path  of  the 
drainage  tube.  The  catheter  is  allowed  to  remain  in  situ  for  about 
three  weeks,  but  this  time  may  be  extended  to  six  or  eight  weeks  if 
necessary. 

Cholecystectomy. — Extirpation  of  the  gall-bladder. 

The  gall-bladder  is  excised  for  rupture  due  to  traumatism :  falls, 
blows,  run-over,  etc.  Gall-bladders  that  are  the  seat  of  malignant 
growth  or  that  are  hopelessly  diseased,  shrunken,  contracted,  etc.,  and 
that  cannot  be  utilized  for  drainage  of  the  liver  should  be  extirpated. 


370  ABDOMEN  AND  BACK. 

Whether  extirpation  of  the  gall-bladder  should  ever  have  the  prefer- 
ence where  a  cholecystostomy  can  be  properly  done  is  questionable. 

In  operations  upon  the  gall-ducts,  etc.,  where  drainage  is  desir- 
able the  gall-bladder,  if  the  cystic  duct  is  patent,  can  be  utilized  for 
this  purpose  with  very  satisfactory  results.  If,  under  these  circum- 
stances it  is  necessary  to  extirpate  the  gall-bladder,  then  drainage  must 
be  provided  by  some  other  plan :  direct  drainage  of  the  common  duct, 
etc. 

Before  he  extirpates  the  gall-bladder  the  operator  must  assure 
himself  that  the  common  duct  is  not  obstructed. 

The  incision  is  vertical,  from  four  to  six  inches  long,  correspond- 
ing to  the  outer  border  of  the  rectus  muscle  and  commencing  above 
at  the  tip  of  the  ninth  costal  cartilage. 

After  the  abdomen  has  been  opened  the  gall-bladder  is  sought. 
It  may  be  distended  and  present  below  the  edge  of  the  liver,  or  it 
may  be  small  and  concealed  beneath  the  free  edge  of  the  liver. 

Adhesions  between  the  gall-bladder  and  neighboring  parts  should 
be  broken  up  with  the  fingers,  and  the  bile-ducts,  especially  the  com- 
mon, should  be  carefully  palpated,  since  extirpation  of  the  gall-bladder 
is  naturally  counter-indicated  if  the  common  duct  is  obstructed.  If 
a  stone  is  found  in  the  common  duct  it  may,  if  soft,  be  crushed  with 
padded  forceps  or  better  with  the  fingers,  or  it  may  be  forced  back 
into  the  bladder  or  else  onward  into  the  duodenum,  or  it  may  be  re- 
moved by  one  of  the  operations  described  below.  After  having  ascer- 
tained that  the  common  duct  is  patent  the  operator  may  proceed  to 
the  excision  of  the  gall-bladder. 

The  liver  is  retracted  upward  and  the  pylorus  downward  out  of 
the  way.  If  the  gall-bladder  is  distended  it  may  be  emptied  with  the 
aspirator.  The  layer  of  peritoneum  which  covers  the  inferior  aspect 
of  the  gall-bladder  and  binds  it  to  the  under  surface  of  the  liver  is 
incised  or  torn,  and  the  gall-bladder  separated  from  the  under  surface 
of  the  liver  subperitoneally,  and,  as  much  as  possible,  bluntly  with  the 
finger,  at  the  same  time  making  traction  upon  the  gall-bladder,  which 
is  held  in  the  grasp  of  a  forceps.  The  separation  of  the  gall-bladder 
is  commenced  at  the  fundus,  gradually  working  backward  toward  the 
neck  of  the  organ.  After  freeing  the  neck  one  continues  along  the 
cystic  duct  as  far  as  its  junction  with  the  common  duct;  finally  the 
gall-bladder  hangs  free,  suspended  only  by  the  cystic  duct.  The  hem- 
orrhage from  the  raw  surface  of  the  liver  is  usually  but  slight  and  may 
be  controlled  by  a  few  minutes'  compression  with  a  hot  gauze  pad  or 


OPERATIONS  UPON  THE  GALL-BLADDER.  371 

by  the  Paquelin  if  necessary.  A  double  silk  or  catgut  ligature  is 
thrown  around  the  cystic  duct  not  too  close  to  its  junction  with  the 
common  duct  and  tied,  and  the  cystic  duct  then  divided  between  the 
ligatures,  and  the  gall-bladder  thus  removed.  The  stump  of  the  cystic 
duct  is  drawn  into  the  incision  by  the  ligature,  which  is  left  long  for 
that  purpose,  and  cauterized;  the  ligature  is  then  cut  short  and  the 
stump  allowed  to  drop  back  into  the  abdomen.  The  edges  of  the  layer 
of  peritoneum  which  bound  the  gall-bladder  to  the  under  surface  of 
the  liver,  and  which  was  torn  to  allow  the  enucleation  of  the  gall- 
bladder, may  be  brought  together  with  a  catgut  suture,  thus  closing 
in  the  raw  area  of  the  liver  and  the  stump  of  the  cystic  duct. 

The  incision  in  the  abdomen  is  closed  without  drainage  with  sev- 
eral interrupted  silk-worm  gut  sutures,  the  edges  of  the  opening  in 
the  parietal  peritoneum  being  first  brought  together  in  the  usual  way 
with  a  continuous  catgut  suture.  In  some  cases  it  is  desirable  to  drain. 
Under  these  circumstances  a  plug  of  strip  gauze,  incased  in  a  layer 
of  rubber  tissue,  is  placed  in  the  abdomen;  the  end  of  the  gauze  may 
be  fixed  to  the  stump  of  the  pedicle,  cystic  duct,  etc.,  with  a  single 
catgut  stitch  to  retain  it  in  place. 

Cholecysto-jejunostomy. — The  formation  of  a  fistulous  opening 
between  the  gall-bladder  and  the  jejunum  in  case  of  inoperable  ob- 
struction of  the  common  duct :  malignant  disease  of  the  common  duct 
or  head  of  pancreas,  etc. 

A  vertical  incision  four  to  six  inches  long  is  made,  correspond- 
ing to  the  outer  border  of  the  right  rectus  muscle,  in  the  semilunar 
line,  commencing  above,  just  below  the  free  border  of  the  ribs  at  the 
tip  of  the  ninth  costal  cartilage. 

Having  cut  through  the  abdominal  wall,  the  distended  gall-blad- 
der usually  presents.  It  is  emptied  as  nearly  completely  as  possible 
of  its  contents  with  the  aspirator  and  then  incised,  and,  if  stones  are 
present,  these  are  removed;  it  is  swabbed  out  dry  with  antiseptic 
gauze  wipes  on  holders  and  then  packed  temporarily  with  strip  gauze 
to  prevent  leakage  during  the  subsequent  steps  of  the  operation. 

A  loop  of  the  jejunum  about  twenty  inches  away  from  its  com- 
mencement (see  "Gastrojejunostomy")  is  secured  and  brought  up,  in 
front  of  the  great  omentum  and  transverse  colon,  into  the  incision  in 
the  abdominal  wall.  The  loop  of  gut  is  emptied  of  its  contents  by 
stripping  between  the  fingers  and  two  constricting  tapes  placed  about 
it  to  prevent  re-entrance  of  contents.  Gauze  pads  are  then  properly 
placed  to  prevent  soiling  of  the  peritoneal  cavity,  and  with  a  straight 


372  ABDOMEN  AND  BACK. 

needle  and  fine  silk  the  gall-bladder,  at  a  convenient  point  near  its 
fundus,  and  the  gut,  opposite  its  mesenteric  border,  are  united  to  each 
other.  This  stitch  takes  a  good,  broad  bite,  including  the  serous  and 
muscular  coats,  but  does  not  pierce  the  whole  thickness  of  the  wall  of 
either  organ.  The  gall-bladder  and  jejunum  are  joined  together  in 
this  way  for  a  distance  of  about  one  and  one-half  inches.  This  needle 
is  then  temporarily  laid  aside,  and  an  incision  one  inch  long  is  made 
in  the  gall-bladder  and  in  the  intestine;  these  openings  are  placed 
opposite  each  other  and  are  shorter  than  the  line  of  suture  which  has 
already  been  applied.  With  a  curved  surgeon's  needle  and  catgut  the 
contiguous  edges  of  these  openings  are  joined  together  all  around  with 
a  continuous  overhand  stitch,  which  penetrates  all  the  coats,  and  thus 
the  communication  between  the  two  organs  is  effected.  After  this  the 
first  needle  carrying  the  fine  silk  thread,  with  which  the  first  half  of 
the  "outside  serous  suture"  was  made,  is  again  taken  up  and  the  second 
half  of  this  "outside  serous  suture"  is  introduced.  In  this  way  the 
gall-bladder  and  the  intestine  are  united  by  a  double  line  of  suture,  one 
joining  the  edges  of  the  openings  to  each  other  all  around,  and  the  other, 
a  non-penetrating  suture,  which  surrounds  this  suture  and  buries  it. 

Having  completed  this  part  of  the  operation,  the  opening  which 
was  made  in  the  fundus  of  the  bladder  for  the  purpose  of  emptying  it 
and  removing  stones,  etc.,  may  be  closed  with  a  Lembert  suture  of  fine 
silk,  or  else  the  margins  of  this  opening  may  be  fixed  to  the  edges  of 
the  abdominal  incision  in  order  to  insure  drainage  for  a  day  or  two 
(cholecystostomy).  The  abdominal  wound  may  be  closed  in  part, 
that  portion  which  is  left  open  being  packed  (see  "Cholecystostomy"). 
If  the  opening  in  the  gall-bladder  is  closed,  then  the  abdominal  in- 
cision may  be  likewise  closed. 

The  result  of  this  operation  is  the  establishment  of  a  communica- 
tion which  allows  the  bile  to  flow  from  the  gall-bladder  into  the  intes- 
tine. The  fistula,  if  an  additional  cholecystostomy  has  been  done, 
closes  readily. 

This  anastomosis  may  also  be  effected  with  the  McGraw  rubber 
ligature,  or  with  the  Murphy  button,  Laplace  forceps,  etc. 

Cholecysto-duodenostomy  with  Murphy  Button. — The  formation 
of  a  fistulous  opening  between  the  gall-bladder  and  the  duodenum, 
the  upper  part  that  adjoins  the  gall-bladder,  for  obstruction  in  the 
common  duct.  This  operation  has  the  advantage  over  the  preceding 
one  that  it  permits  the  bile  to  enter  the  upper  part  of  the  duo- 
denum where  it  may  be  used  in  the  process  of  digestion. 


OPERATIONS  UPON  THE   GALL-BLADDER. 


373 


A  vertical  incision  four  to  six  inches  long  is  made  from  the  tip 
of  the  ninth  costal  cartilage,  downward,  along  the  outer  border  of 
the  rectus  muscle,  in  the  linea  semilunaris,  or  a  vertical  incision 
(Murphy)  may  be  emploj'ed  which  commences  above,  just  below  the 
free  border  of  the  ribs  and  reaches  downward  for  a  distance  of  three 
or  four  inches;  this  incision  is  placed  two  inches  to  the  right  of  and 
parallel  with  the  middle  line,  penetrating  between  the  fibers  of  the 
rectus  muscle. 

Having  cut  through  the  abdominal  wall,  the  gall-bladder  is  lo- 
cated and  drawn  into  the  wound  and  steadied  there;   then  the  duo- 


Fig.    162. — Cholecysto-duodenostomy    with    Murphy    Button. 


denum  is  secured  and  drawn  into  the  wound.  The  duodenum  is 
cleared  of  its  contents  by  gentle  stripping  with  the  fingers,  and  a 
compressor  applied  to  prevent  the  re-entrance  of  contents.  Pads  are 
arranged  to  protect  the  peritoneal  cavity,  and  with  a  straight  needle 
a  silk  thread  is  introduced  in  the  wall  of  the  gut  in  the  fashion  of  a 
purse-string.  Each  leg  of  this  suture  should  include  about  one  and 
one-half  inches  of  the  length  of  the  gut  and  be  in  a  straight  line ;  it 
should  be  made  with  three  punctures  of  the  needle,  each  bite  includ- 
ing about  one-third  inch  and  passing  through  the  entire  thickness  of 
the  wall  of  the  gut ;  the  second  limb  of  this  suture  is  then  made  with 
the  same  thread  in  the  reverse  direction  parallel  with  the  first  and  dis- 
tant from  it  about  one-half  inch,  finally  terminating  alongside  of  where 
the  needle  first  entered  in  commencing  the  suture.     Corresponding  to 


374  ABDOMEN  AND  BACK. 

the  point  where  the  thread  turns  back  to  form  the  second  half  of  the 
suture  a  little  slack,  or  loop,  should  be  left.  With  the  ends  of  this 
running  stitch  the  first  loop  of  a  surgeon's  knot  is  taken.  The  gut  is 
then  incised  between  the  two  rows  of  suture  for  a  distance  correspond- 
ing to  two-thirds  the  length  of  the  diameter  of  the  button  to  be  used 
(No.  1  or  2  preferable),  the  incision  being  shorter  than  the  suture 
line.  The  method  of  applying  the  purse-string  suture  is  similar  to 
that  employed  in  "Lateral  Intestinal  Anastomosis"  (Fig.  145). 
The  male  half  of  the  button,  grasped  with  a  thumb  forceps,  is 
then  slipped  sideways  into  the  opening  in  the  gut  and  the  running 
string  drawn  tight  about  it  and  tied.  This  half  of  the  button  is  thus 
fixed  in  the  opening  in  the  intestine  and  steadied  until  the  female  half 
has  been  fixed  in  the  gall-bladder. 

If  the  gall-bladder  is  distended,  it  may  be  first  emptied  with 
the  aspirator.  A  similar  running  suture  and  incision  are  made  in 
the  gall-bladder  at  a  convenient  point  near  the  fundus,  and  any 
stones  that  are  present  may  be  extracted.  After  this  the  female  half 
of  the  button  is  introduced  into  the  opening  and  the  purse-string 
drawn  tight  and  tied;  the  two  halves  of  the  button  are  then  gently 
and  steadily  forced  home. 

It  might  be  wise  in  addition  to  establish  a  biliary  fistula  by  in- 
cising the  gall-bladder  and  sewing  the  edges  of  the  opening  thus  made 
into  the  abdominal  wound,  as  already  described  (cholecystostomy). 
As  a  rule,  this  is  unnecessary,  however,  and  the  abdominal  wound  may 
be  closed  without  drainage. 

The  anastomosis  between  the  gall-bladder  and  duodenum  may 
also  be  accomplished  with  the  simple  suture  or  with  the  McGraw 
rubber  ligature,  Laplace  forceps,  etc. 

Cholecysto-colostomy. — The  establishment  of  a  fistulous  commu- 
nication between  the  gall-bladder  and  colon.  This  operation  has  been 
done  in  cases  of  inoperable  obstruction  of  the  common  duct  so  as  to 
provide  an  exit  for  the  bile  to  escape.  The  technique  of  this  operation 
is  quite  similar  to  that  of  the  operations  just  described.  The  trans- 
verse colon  is  found  immediately  adjacent  to  the  gall-bladder  and 
the  anastomosis  between  the  gall-bladder  and  it  is  easily  effected.  It 
is  claimed  that  the  functions  of  the  patient  do  not  suffer  from  thus 
diverting  the  bile  away  from  the  small  intestine.  The  objection  has 
been  made  against  this  operation  that  the  gall-bladder  and  secondarily 
the  liver  are  more  apt  to  become  infected  from  the  large  intestine, 
colon  bacillus,  etc. 


OPERATIONS  UPON  THE  GALL-DUCTS.  375 

OPERATIONS  UPON  THE  GALL=DUCTS. 

Choledochotomy. — Incision  into  the  common  bile-duct.  This 
operation  is  performed  for  the  purpose  of  removing  impacted  calculi. 

Choledocho-lithectomy. — Removal  of  a  stone  or  stones  through 
an  incision  in  the  lommon  duct.  A  cushion  or  sand-bag,  placed  under 
the  lower  dorsal  region  as  recommended  by  Eobson,  has  the  effect  of 
throwing  the  common  duct  forward  toward  the  abdominal  incision, 
thus  making  it  much  more  easy  of  access. 

The  usual  incision  is  made,  reaching  from  the  tip  of  the  ninth 
costal  cartilage  downward  for  a  distance  of  four  or  five  inches. 

Where  the  common  duct  has  been  obstructed  by  an  impacted  stone 
for  some  time  the  gall-bladder  is  likely  to  be  found  contracted, 
shrunken,  and  adherent  to  adjacent  structures  and  may  or  may  not 
contain  calculi. 

Before  interfering  with  the  gall-bladder  a  careful  examination 
should  be  made  of  the  bile-ducts — hepatic,  cystic,  and  common — for 
calculi.  The  common  bile-duct  with  the  portal  vein  behind  it  and 
the  hepatic  artery  upon  its  left  side  is  situated  deep  in  the  abdomen 
between  the  folds  of  the  lesser,  gastro-hepatic,  omentum,  near  its  right, 
free  border,  and  may  be  palpated  for  its  entire  length  with  two  fingers 
of  the  left  hand  in  the  foramen  of  Winslow  and  the  thumb  opposed 
anteriorly.  The  normal  common  duct  may  not  be  recognized  in  many 
cases,  but  if  there  is  a  stone  present  in  the  duct  and  this  condition 
has  been  existing  for  some  time,  then  the  duct  is  likely  to  have  become 
dilated,  pouched,  and  its  wall  thickened  and  may  be  more  readily 
located  by  the  examining  fingers,  especially  since  the  stone  itself  is 
a  good  guide.  Several  lymphatic  nodes  which  are  situated  between 
the  layers  of  the  gastro-hepatic  omentum  near  its  right  free  edge,  may 
be  felt  and  might  be  mistaken  for  stones  in  the  common  duct,  espe- 
cially as  they  are,  at  times,  found  enlarged  and  indurated  as  a  result 
of  disease  of  the  gall-ducts  or  of  the  adjacent  organs.  In  order  to 
reach  the  common  duct  the  liver  and  gall-bladder  must  be  lifted  well 
upward  and  the  pyloric  end  of  the  stomach  drawn  downward.  It  may 
be  found  necessary  to  break  up  adhesions  between  the  neighboring 
organs,  working  bluntly  with  the  fingers  down  toward  the  common 
duct  between  the  pyloric  end  of  the  stomach  and  the  under  surface 
of  the  liver.     Care  must  be  exercised  not  to  tear  intestines,  etc. 

If  a  stone  is  discovered  in  the  common  duct,  the  abdominal 
incision  may  be  enlarged,  carrying  it  upward   and   inward  toward 


376  ABDOMEN  AND  BACK. 

the  ensiform  cartilage  and  partly  dividing  the  rectus  muscle. 
Through  this  incision  good  access  can  be  had  to  the  common  duct. 

Before  proceeding  to  the  removal  of  the  stone  or  stones  from 
the  common  duct,  the  gall-bladder  should  be  incised,  after  being  first 
emptied  with  the  aspirator  if  it  is  distended;  any  stones  that  are 
present  are  removed  and  its  interior  swabbed  out  dry  with  antiseptic 
gauze  wipes  on  holders.  The  gall-bladder,  having  been  thus  emptied 
and  swabbed  out,  is  packed  temporarily  with  strip  gauze  to  prevent 
leakage,  and  the  operator  then  directs  his  effort  to  the  removal  of  the 
stone  or  stones  from  the  common  duct. 

The  liver  and  gall-bladder  should  be  well  retracted,  drawn  up- 
ward, and  the  pyloric  end  of  the  stomach  downward.  Two  fingers  of 
the  left  hand  are  introduced,  behind  the  common  duct,  into  the  fora- 
men of  Winslow  and  the  duct  drawn  forward  toward  the  abdominal 
incision  and  thus  steadied  while  an  incision  is  made  through  its  wall, 
cutting  directly  down  upon  the  stone.  The  incision  into  the  duct 
should  be  sufficiently  liberal.  The  stone  is  thus  removed.  Some  bile 
escapes  through  the  opening  in  the  duct,  but  this  is  caught  upon  the 
gauze  pads  which  are  previously  arranged  to  prevent  soiling  of  the 
peritoneal  cavity.  The  duct  should  be  carefully  sounded  for  addi- 
tional stones  either  with  the  finger  or  a  large  probe. 

The  incision  in  the  duct  may  be  closed  or  else  left  open  for 
drainage.  If  it  is  decided  to  close  the  opening  this  is  done  with  a 
sufficient  number  of  interrupted  silk  sutures.  These  sutures  should 
approximate  the  edges  of  the  incision,  but  should  not  go  through  the 
entire  thickness  of  the  wall  of  the  duct;  they  should  not  penetrate 
the  mucous  membrane  layer.  The  duct  may  be  left  open  and  drained, 
especially  if  symptoms  of  septic  liver  infection  have  been  present. 
A  rubber  drainage  tube  of  such  thickness  that  it  makes  a  snug  fit  within 
the  common  duct  is  introduced  and  fixed  to  the  edge  of  the  incision 
with  a  silk  stitch  and  the  rest  of  the  opening  in  the  duct  closed  with 
several  interrupted,  penetrating,  silk  sutures.  The  ends  of  these  pene- 
trating silk  sutures  are  left  sufficiently  long  so  that  they  may  be 
drawn  out  through  the  abdominal  incision.  After  the  lapse  of  one 
or  two  weeks  when  the  tube  is  removed  the  silk  sutures  may  also  be 
removed  by  making  traction  upon  them.  Strip  gauze  is  packed  down 
alongside  of  the  tube  as  far  as  the  incision  in  the  duct.  If  only  tem- 
porary drainage  is  required  a  wick  of  rolled  strip  gauze  may  be  used, 
the  end  of  the  wick  being  fixed  to  the  edge  of  the  opening  in  the  duct 
with  a  catgut  suture  to  prevent  its  becoming  displaced. 


OPERATIONS  UPON  THE  GALL-DUCTS.  377 

The  gall-bladder,  which  has  already  been  opened  and  evacuated 
in  the  early  part  of  the  operation  should  be  utilized  for  the  purpose 
of  draining  the  liver  either  by  performing  a  cholecystostomy  as  already 
described  or  else  according  to  the  method  of  Poppert.  Under  excep- 
tional circumstances — for  example,  where  the  cystic  duct  is  obstructed 
or  distorted — it  may  be  wise  to  extirpate  the  gall-bladder. 

The  incision  in  the  abdomen  is  closed  with  interrupted  sutures 
of  silk-worm  gut,  except  for  the  space  that  is  left  open  to  permit  the 
exit  of  the  drainage  tubes,  gauze,  etc. 

Choledocho-lithotripsy. — Crushing  a  stone  within  the  common 
bile-duct  without  making  an  incision  into  the  duct. 

This  is  not  advisable  unless  the  calculus  is  quite  soft.  It  may 
be  done  with  padded  forceps  or  better  with  the  fingers.  At  times  it  is 
possible,  by  massaging  the  common  duct  with  the  fingers,  to  force 
a  stone  through  the  orifice  of  the  duct  into  the  duodenum.  If  the  duct 
is  not  incised  the  opportunity  to  explore  the  duct  with  the  finger  or 
probe  is  not  offered. 

Even  if  the  effort  to  crush  the  calculus  or  force  it  through  the 
orifice  of  the  common  duct  into  the  duodenum  has  been  successful, 
it  will  be  wise  in  some,  if  not  all,  cases  to  establish  drainage  of  the 
liver  and  bile  passages  by  performing  a  cholecystostomy. 

Removal  of  Calculi  from  the  Common  Duct  through  the  Duo- 
denum.— This  is  the  method  of  McBurney  and  Kocher.  For  calculi 
which  are  impacted  low  down  in  the  retroduodenal  portion  of  the 
duct  and  which  cannot  be  reached  through  an  incision  in  the  duct 
itself. 

Through  the  usual  incision  from  the  tip  of  the  ninth  costal 
cartilage  downward  the  abdomen  is  opened.  The  ducts  are  palpated 
and  the  gall-bladder  evacuated  and  tamponed  temporarily  as  described 
in  the  preceding  operation. 

If  necessary  to  get  more  room  so  as  to  facilitate  the  succeeding 
steps  of  the  operation  the  incision  may  be  enlarged  upward  and  in- 
ward parallel  with  the  lower  free  border  of  the  ribs  toward  the  ensi- 
form  cartilage,  cutting  partly  through  the  rectus  muscle.  The  liver 
and  gall-bladder  should  be  retracted  well  upward  and  with  the  two 
fingers  passed  into  the  foramen  of  Winslow  and  the  thumb  opposed 
anteriorly,  the  common  duct  and  the  duodenum  are  pulled  forward 
toward  the  abdominal  incision  and  thus  steadied.  The  stone  within 
the  common  duct  can  be  felt  through  the  wall  of  the  duodenum.  The 
duodenum  is  incised,  making  an  opening  from  one  to  one  and  one- 


378  ABDOMEN  AND  BACK. 

half  inches  long,  either  longitudinal  or  transverse  (Kocher),  and  the 
duodenum  thus  entered.  Any  contents  that  escape  from  the  duo- 
denum are  sponged  away  or  caught  on  gauze  pads  arranged  for  this 
purpose  so  as  to  protect  the  peritoneal  cavity  from  soiling.  The  stone 
may  often  times  be  felt  and  seen  presenting  in  the  mouth  of  the  com- 
mon duct,  which  is  located  on  the  inner,  posterior  aspect  of  the  duo- 
denal wall  about  three  inches  distant  from  the  pylorus.  The  stone 
may  be  extracted  with  the  forceps,  or  before  this  can  be  accomplished 
it  may  be  necessary  to  stretch  or  incise  the  orifice  of  the  duct.  If  it 
is  necessary  to  incise  the  margin  of  the  orifice  of  the  duct  this  is 
done  by  snipping  with  the  scissors  in  an  upward  direction  for  a  dis- 
tance of  from  one-half  to  three-fourths  of  an  inch. 

The  calculus  may  be  impacted  above  the  orifice  of  the  duct,  and 
there  may  be  some  difficulty  in  locating  the  orifice  of  the  duct,  or  the 
stone  may  be  so  firmly  wedged  in  the  duct  that  it  cannot  be  readily 
delivered  through  the  orifice.  Under  these  conditions,  instead  of  at- 
tempting to  draw  the  stone  out  through  the  orifice  of  the  common 
duct  it  may  be  extracted  by  cutting  down  directly  upon  it  through  the 
walls  of  the  duodenum  and  common  duct.  When  the  stone  is  re- 
moved and  the  obstruction  of  the  common  duct  relieved  there  is  some 
escape  of  bile  from  the  duct  into  the  intestine.  This  should  be  pre- 
vented from  soiling  the  peritoneal  cavity.  The  duct  is  sounded  for 
additional  stones  either  with  the  finger  or  a  thick  probe  introduced 
through  the  enlarged  orifice  or  incision.  The  incision  that  was  made 
in  the  walls  of  the  duodenum  and  common  duct  for  the  purpose  of 
extracting  the  stone  is  allowed  to  remain  open,  thus  establishing  a 
fistulous  communication  between  the  common  duct  and  duodenum, 
choledocho-duodenostomy  interna.  The  contiguous  edges,  however,  of 
the  opening  in  the  duodenum  and  common  duct  may  be  sewed  to- 
gether with  several  catgut  sutures ;  owing  to  the  inflammatory  process 
that  accompanies  stone  impaction  of  the  common  duct  the  wall  of 
the  common  duct  and  wall  of  the  duodenum  are  usually  found  already 
adherent  to  each  other,  and  under  these  conditions  the  sutures  might 
be  omitted  with  safety. 

The  incision  in  the  duodenum  is  closed  with  a  non-penetrating 
Lembert  suture  of  silk. 

The  gall-bladder,  which  has  already  been  opened  and  evacuated 
in  the  early  part  of  the  operation,  should  be  treated  as  in  the  pre- 
ceding operation :  i.e.,  it  should  be  utilized  for  the  purpose  of  drain- 
ing the  liver  either  by  performing  a  cholecystostomy  as  already  de- 


SURGICAL  ANATOMY  OF  THE  PANCREAS.  379 

scribed  or  else  according  to  the  method  of  Poppert.  Under  exceptional 
circumstances — for  example,  where  the  cystic  duct  is  obstructed  or 
distorted — it  may  be  wise  to  extirpate  the  gall-bladder. 

The  incision  in  the  abdomen  is  closed  with  interrupted  sutures 
of  silk-worm  gut,  except  for  the  space  that  is  left  open  to  permit  the 
exit  of  the  drainage  tubes,  gauze,  etc. 

Removal  of  Calculi  from  Common  Duct  through  Incision  in  Sec- 
ond Part  of  Duodenum. — The  writer  has  found  the  second  part  of  the 
duodenum  convenient  for  incision,  etc.,  for  the  purpose  of  extracting 
stones  impacted  low  down  in  the  common  duct.  In  order  to  gain 
access  to  the  second  part  of  the  duodenum  it  is  necessary  to  reflect  the 
great  omentum  and  transverse  colon  upward  toward  the  liver.  The 
second  part  of  the  duodenum  is  found  lying  to  the  right  of  the  body 
of  the  second  lumbar  vertebra  deep  in  the  abdomen.  The  stone  may 
be  felt  through  the  wall  of  the  duodenum.  Deep,  broad  retractors  and 
gauze  abdominal  pads  are  introduced  and  the  duodenum  incised.  An 
opening  one  inch  long  will  usually  suffice.  The  orifice  of  the  common 
duct  lies  almost  immediately  opposite  the  incision.  Escaping  intes- 
tinal contents  may  be  caught  with  gauze  swabs  and  wiped  away  or 
gauze  pads  with  tapes  attached  may  be  introduced  into  the  interior 
of  the  gut  above  and  below  the  incision  for  the  purpose  of  blocking 
it  and  checking  the  escape  of  intestinal  material. 

The  stone  or  stones  are  extracted  from  the  common  duct  by  any 
of  the  methods  described  in  the  preceding  operation.  The  opening  in 
the  duodenum  is  closed  with  a  continuous  Lembert  suture,  the  parts 
wiped  clean  with  a  moist  gauze  pad,  and  the  great  omentum  and  trans- 
verse colon  drawn  down  into  their  normal  position. 

THE  PANCREAS. 

Surgical  Anatomy  of  the  Pancreas. — The  pancreas  is  an  elon- 
gated glandular  organ  from  six  to  eight  inches  long,  its  breadth  equal 
to  about  one-fourth  its  length;  it  is  about  one-half  inch  in  thickness 
from  before  backward.  It  is  placed  transversely  in  the  upper  back  part 
of  the  abdominal  cavity,  lying  behind  the  stomach  across  the  body  of 
the  second  lumbar  vertebra.  It  consists  of  a  head,  body,  and  tail, 
the  tail  abutting  against  the  spleen. 

The  head  lies  to  the  right  of  the  vertebral  column,  resting  upon 
the  inferior  vena  cava,  Tight  crus  of  the  diaphragm,  and  right  renal 
vessels,  and  separated  from  the  inner  border  of  the  right  kidney  by 


380 


ABDOMEN  AND  BACK. 


the  second  part  of  the  duodenum.  The  common  bile-duct  is  located 
between  the  second  part  of  the  duodenum  and  the  head  of  the  pan- 
creas. 

The  body  of  the  pancreas  lies  opposite  the  second  lumbar  ver- 
tebra upon  the  crus  (left)  of  the  diaphragm,  aorta,  thoracic  duct,  etc. 
To  the  left  of  the  vertebral  column  it  is  in  relation  with  the  renal 
vessels  and  left  kidney.  In  front  of  the  pancreas  are  the  peritoneum, 
stomach,  and  transverse  colon.  The  splenic  artery  and  vein  run  along 
its  upper  border.  Its  lower  border  is  in  relation  with  the  third  part 
of  the  duodenum,  and  passing  forward  between  this  part  of  the  duo- 
denum and  the  lower  border  of  the  pancreas  are  the  superior  mesen- 
teric artery  and  vein. 


Fig.  163.— Segment  of  Wall  of  Duode- 
num showing  the  Orifices  of  the  Com- 
mon Bile-duct  and  Pancreatic  Duct.  The 
two  ducts  open  in  common  through  the 
ampulla  of  Vater.  C,  common  duct;  P, 
pancreatic    duct. 


Fig.  164.— Segment  of  Wall  of  Duode- 
num showing  the  Orifices  of  the  Com- 
mon Bile-duct  and  Pancreatic  Duct. 
Each  duct  has  a  separate  opening.  C, 
common   duct;    P,   pancreatic   duct. 


The  tail  of  the  pancreas  projects  to  the  left  as  far  as  the  spleen, 
to  which  it  is  connected  by  a  fold  of  peritoneum,  ligamentum  pan- 
creatico-lienale. 

The  pancreas  is  covered  by  the  peritoneum  upon  its  anterior  sur- 
face only.  The  transverse  mesocolon  passes  backward,  and  upon  reach- 
ing the  pancreas  its  layers  separate;  the  upper  layer  passes  upward, 
covering  the  front  surface  of  the  pancreas,  and  lines  the  back  wall 
of  the  upper  part  of  the  abdomen  (lesser  peritoneal  sac). 

The  pancreatic  duct,  duct  of  Wirsung,  courses  through  the  entire 
length  of  the  organ  from  left  to  right  and  empties  into  the  second 
part  of  the  duodenum.  The  duct  penetrates  the  inner  wall  of  the 
duodenum  very  obliquely  and  in  close  relationship  with  the  common 
bile-duct  and  usually  terminates  by  opening  into  the  lower  dilated 
part  of  the  common  bile-duct:    the  ampulla  of  Vater.     The  orifice 


OPERATIONS  UPON  THE  PANCREAS.  381 

of  the  common  duct  is  marked  by  a  papilla  which  is  situated  upon 
the  inner  wall  of  the  second  part  of  the  duodenum  from  three  to  four- 
inches  below  the  pylorus.  In  some  cases  the  pancreatic  duct  does  not 
terminate  in  the  ampulla  of  Vater,  but  opens  into  the  duodenum  in- 
dependently of  the  common  bile-duct  through  a  separate  orifice  upon 
the  summit  of  the  papilla. 

A  calculus  lodged  in  the  ampulla  of  Vater  may  compress  the 
end  of  the  pancreatic  duct  and  cause  obstruction  to  the  escape  of  the 
pancreatic  juice  into  the  duodenum  or,  as  pointed  out  by  Opie,  in 
those  cases  where  the  pancreatic  duct  opens  into  the  ampulla  of  Vater 
a  small  stone  obstructing  the  duodenal  orifice  of  the  ampulla  of  Vater 
might  serve  to  divert  the  stream  of  infected  bile  from  the  common 
bile-duct  into  the  pancreatic  duct  (see  Fig.  163)  and  thus  lead  to  seri- 
ous disease  of  the  pancreas — hemorrhagic  pancreatitis  and  gangrene- 
In  addition  to  the  pancreatic  duct  already  described,  that  of  Wir- 
sung,  there  is  a  second  one  normally  present,  the  duct  of  Santorini.. 
The  orifice  of  the  duct  of  Santorini  can  usually  be  demonstrated  upon 
the  inner  wall  of  the  duodenum  about  one  inch  nearer  the  pylorus  than 
the  papilla  that  marks  the  opening  of  the  common  bile-duct  and  duct 
of  Wirsung.  Within  the  pancreas  the  duct  of  Santorini  usually  an- 
astomoses with  the  duct  of  Wirsung.  In  some  exceptional  cases  the 
duct  of  Santorini  is  larger  than  the  duct  of  Wirsung  and  may  func- 
tionate for  the  latter. 

The  induration  that  results  from  chronic  inflammatory  processes 
that  involve  the  head  of  the  pancreas  and  which  are  frequently  asso- 
ciated with  cholelithiasis  and  the  passage  of  gall-stones  through  the 
common  bile-duct  may  cause  symptoms  of  obstructive  jaundice  by 
compression  of  the  common  duct;  malignant  growths  involving  the 
head  of  the  pancreas  may  have  a  similar  effect  upon  the  common  duct.. 

OPERATIONS  UPON  THE  PANCREAS. 

The  operative  treatment  of  diseases  of  the  pancreas  forms  a  com- 
paratively new  chapter  in  surgery.  According  as  the  functions  of  the- 
organ  and  the  pathological  processes  that  affect  it  become  better 
understood  the  results  of  surgical  interference  will  without  doubt  be- 
come more  satisfactory. 

Operative  procedures  are  undertaken  for  the  purpose  of  treating 
injuries,  inflammatory  conditions,  and  new  growths  in  the  shape  of.' 
cysts  and  solid  tumors. 


382  ABDOMEN  AND  BACK. 

Fat  Necrosis. — Injuries  and  inflammatory  conditions  that  are 
accompanied  by  a  destruction  of  the  tissue  of  the  pancreas  are  very 
likely  to  be  complicated  by  necrosis  of  the  fatty  tissue  in  and  about 
the  pancreas  and  in  the  mesentery,  omentum,  subperitoneal  connective 
tissue,  etc.  This  phenomenon  of  fat  necrosis  is  caused  by  the  direct 
action  of  the  pancreatic  secretion  that  escapes  from  the  injured  gland. 
Langerhans  and  Mexner  have  demonstrated  a  ferment  in  the  pan- 
creatic juice  which  is  capable  of  reducing  the  living  fat  into  its  fatty 
acid  and  glycerin,  and  this  is,  no  doubt,  the  active  agent  in  producing 
the  peculiar  condition  of  fat  necrosis.  After  the  fat  has  been  split 
up  in  this  manner  the  glycerin  is  absorbed  and  the  fatty  acid  remain- 
ing combines  with  lime  salts  and  thus  there  are  produced  little,  opaque 
areas  of  a  dull  white  or  yellow  color  in  place  of  the  fatty  tissue  that 
has  been  broken  up.  When  the  abdomen  is  opened  the  omentum,  etc., 
are  found  studded  with  these  areas.  These  spots  are  flat,  and  vary  in 
size  from  a  pin-head  to  a  pea  or  larger  and  stand  out  in  marked  con- 
trast to  the  bright,  glistening  yellow  of  the  normal  fat.  Eecognition 
of  this  condition  of  fat  necrosis  during  the  course  of  operation  is  of 
the  greatest  significance  to  the  surgeon  and  should  direct  his  atten- 
tion at  once  to  the  pancreas  as  the  seat  of  grave  disease  or  injury. 

Incisions  to  Obtain  Access  to  the  Panceeas. — The  pancreas 
is  situated  very  deep  in  the  upper  back  part  of  the  abdomen.  It  is 
usually  approached  from  in  front,  the  incision  being  placed  above  the 
umbilicus  in  the  middle  line  or  to  one  or  the  other  side  of  the  middle 
line,  penetrating  between  the  fibers  of  the  rectus  muscle.  After  the 
abdomen  has  been  opened,  it  will  be  necessary,  in  order  to  reach  the 
pancreas,  to  enter  the  lesser  peritoneal  sac.  This  may  be  accomplished 
through  an  opening  which  is  made  for  the  purpose  in  the  lesser  omen- 
tum, gastro-hepatic  ligament,  or  through  an  opening  corresponding 
to  the  lower  border  of  the  stomach  which  is  made  in  the  gastro-colic 
ligament.  Access  to  the  pancreas  may  also  be  gained  through  a  rent 
torn  in  the  transverse  mesocolon;  the  transverse  colon  and  the  great 
omentum  are  reflected  upward  and  the  mesocolon  penetrated  from 
below  bluntly  in  order  to  avoid  injury  of  the  arteria  colica  media. 
The  head  of  the  pancreas  may  be  exposed  by  penetrating  between  the 
duodenum  and  pancreas  after  the  peritoneum  which  is  reflected  over 
its  anterior  surface  has  been  incised. 

The  pancreas  has  also  been  exposed  through  an  oblique  incision 
commencing  near  the  tip  of  the  twelfth  rib  and  passing  forward  toward 
the  umbilicus;   or  beginning  below  the  tip  of  the  twelfth  rib  the  in- 


OPERATIONS  UPON  THE  PANCREAS.  383 

cision  may  be  carried  forward,  running  below  and  parallel  with  the 
free  border  of  the  costal  cartilages. 

By  a  Retroperitoneal  Method. — The  pancreas  may  be  approached 
through  an  incision  in  the  lumbar  region.  The  incision  is  placed 
along  the  outer  border  of  the  erector  spinge  muscle  commencing  at 
the  twelfth  rib  and  carried  downward  or  downward  and  outward. 
This  route  may  be  employed  for  the  purpose  of  evacuating  cysts,  ab- 
scesses, etc.,  if  the  head  or  tail  of  the  organ  is  the  part  chiefly  affected 
and  if  the  tumor  occupies  a  position  well  to  one  side  or  the  other  of 
the  middle  line.  A  cyst,  etc.,  under  favorable  conditions,  may  be  thus 
emptied  without  entering  the  peritoneal  cavity. 

Drainage  should  be  provided  in  all  operations  where  the  pan- 
creas is  found  injured  or  diseased  so  as  to  prevent  as  far  as  possible 
the  entrance  into  the  peritoneal  cavity  of  pancreatic  juice,  etc.,  in 
the  event  of  leakage. 

For  Injuries. — Owing  to  its  protected  position,  the  pancreas  is 
seldom  the  seat  of  injury  without  adjacent  important  organs  being 
seriously  involved.  In  stab  and  gunshot  wounds  of  the  stomach  the 
pancreas  is  frequently  found  injured  as  well.  In  severe  non-pene- 
trating traumatisms  of  the  abdomen,  run-over,  kicks,  etc.,  where  the 
pancreas  is  injured,  the  intestine,  duodenum,  is  likely  to  be  ruptured. 
In  operations  for  wounds  of  the  abdominal  viscera,  especially  if  the 
stomach  or  duodenum  is  involved,  the  condition  of  the  pancreas  should 
always  be  carefully  investigated.  The  pancreas  may  be  reached  by 
entering  the  lesser  peritoneal  cavity  through  an  opening  which  is 
made  for  the  purpose  in  the  gastro-colic  ligament.  This  is  detached 
for  a  sufficient  extent  from  the  lower  border  of  the  stomach. 

Wounds  of  the  pancreas  are  to  be  closed  with  deep  and  superficial 
sutures  of  catgut  in  order  to  control  the  hemorrhage  and  to  prevent 
as  far  as  possible  the  leakage  of  pancreatic  secretion  into  the  peri- 
toneal cavity.  The  presence  of  this  material  in  the  peritoneal  cavity 
is  capable  of  setting  up  a  fatal  peritonitis  and  is  the  cause  of  the  fat 
necrosis.  Owing  to  the  friable  nature  of  the  pancreatic  tissue,  diffi- 
culty may  be  experienced  in  getting  the  sutures  to  hold.  If  the  tail  of 
the  pancreas  is  the  part  involved  the  injured  portion  may  be  tied  off 
and  excised.  Proper  drainage  should  be  provided  in  all  of  these  cases. 
A  drainage  tube  surrounded  with  strip  gauze  is  introduced  through 
the  opening  in  the  gastro-colic  ligament  down  to  the  site  of  the  wound 
in  the  pancreas,  its  free  end  emerging  through  the  abdominal  incision 
near  the  umbilicus. 


384  ABDOMEN  AND  BACK. 

Needless  to  say,  accompanying  wounds  of  the  stomach,  intestine, 
spleen,  kidneys,  etc.,  should  be  properly  disposed  of.  The  abdomen  is 
flushed  out  with  saline  solution  and  the  incision  closed  for  part  of 
its  length  with  interrupted  silk  sutures. 

For  Cysts. — The  exact  nature  of  the  origin  of  all  pancreatic  cysts 
is  not  known.  A  considerable  number  are,  no  doubt,  caused  by  occlu- 
sion of  the  larger  or  smaller  ducts  by  calculi  or  they  may  be  caused 
by  stenosis  of  the  smaller  ducts  due  to  chronic  inflammatory  processes 
seated  in  the  pancreas  itself  or  extending  from  adjacent  organs.  The 
cysts  usually  first  make  their  presence  known  in  the  shape  of  a  pal- 
pable tumor  occupying,  as  a  rule,  the  upper  part  of  the  abdominal 
cavity. 

The  abdominal  incision  is  placed  above  the  umbilicus,  in  the 
linea  alba  or  to  one  or  the  other  side  of  the  middle  line.  When  the 
abdomen  is  opened  the  cyst  may  be  found  presenting  forward  through 
the  gastro-hepatic  ligament,  above  the  stomach,  pushing  the  stomach 
down  or  else — and  this  is  more  common — it  may  present  below  the 
stomach,  between  it  and  the  transverse  colon,  forcing  the  stomach  up- 
ward toward  the  liver  and  the  transverse  colon  downward.  In  still 
other  cases  the  cyst  may  dissect  its  way  forward  between  the  layers  of 
the  transverse  mesocolon  pushing  the  transverse  colon  in  front  of  it 
or  it  may  grow  downward  and  forward  so  as  to  present  below  the 
transverse  colon. 

The  cyst  may  be  emptied  and  drained  or  an  attempt  may  be  made 
to  extirpate  it. 

Evacuation  and  Drainage. — After  the  cyst  has  been  exposed  its 
contents  are  evacuated  as  nearly  completely  as  possible  with  the  aspi- 
rator, and  then  it  is  incised.  The  edges  of  the  incision  are  sutured  to 
the  peritoneum  and  deep  muscle  in  the  abdominal  incision.  The  ab- 
dominal incision  is  closed  for  part  of  its  extent  with  interrupted  silk 
sutures  and  a  large  glass  drainage  tube  surrounded  with  strip  gauze 
is  introduced  down  into  the  bottom  of  the  cyst. 

Without  preliminary  evacuation,  the  cyst  may  be  fixed  to  the 
edges  of  the  abdominal  incision  and  opened  later,  after  adhesions  have 
had  time  to  form. 

If  the  cyst  is  small  and  cannot  be  brought  up  into  the  abdominal 
incision  a  purse-string  suture  may  be  applied  about  the  margin  of  the 
opening  in  the  cyst  and  a  large  rubber  tube  introduced.  The  purse- 
string  is  drawn  tight,  thus  closing  the  edges  of  the  opening  securely 
about  the  tube.    The  tube  may  be  fixed  to  the  margin  of  the  incision  in 


OPERATIONS  UPON  THE  PANCREAS.  385 

the  cyst  with  a  catgut  suture  in  order  to  make  certain  that  it  will 
not  become  displaced.  Strip  gauze  is  packed  around  the  drainage  tube 
down  to  the  site  of  the  incision  in  the  cyst.  The  abdominal  incision 
is  closed  for  part  of  its  extent  with  interrupted  silk  sutures. 

An  additional  counter-opening  with  the  object  of  providing  still 
better  drainage  may  be  made  in  the  lumbar  region,  or  after  the  diag- 
nosis has  been  made  the  anterior  abdominal  incision  may  be  closed  and 
the  cyst  drained  exclusively  through  a  lumbar  incision. 

In  some  cases  following  this  plan  of  treatment  a  fistula  persists 
for  a  long  time,  but,  as  a  rule,  it  closes  ultimately. 

Extirpation. — Extirpation  of  a  pancreatic  cyst  either  partial  or 
complete  is  seldom  advisable.  The  adhesions  are  frequently  found  to 
be  very  extensive  and  firm  and  under  such  conditions  extirpation  would 
be  difficult  and  dangerous. 

In  some  cases  the  adhesions  are  of  such  a  character  that  the  tumor 
can  be  isolated  by  blunt  dissection,  working  with  the  fingers  very 
close  to  the  wall  of  the  cyst  and  occasionally  doubly  ligating  and 
dividing  bands  of  adhesions.  After  the  cyst  has  been  entirely  sepa- 
rated the  pedicle  that  joins  the  cyst  to  the  pancreas  must  be  secured. 
This  is  ligatured  and  clamped  before  it  is  divided  in  removing  the 
cyst.     In  these  cases  also  drainage  should  be  provided. 

The  abdominal  incision  is  closed  in  part  with  interrupted  silk 
sutures. 

For  Acute  Pancreatitis. — The  process  which  has  been  described 
as  acute  hemorrhagic  pancreatitis  is  probably  caused  by  a  retrograde 
infection  extending  along  the  pancreatic  duct  either  from  the  duo- 
denum or  common  bile-duct.  Opie  says  that  a  small  calculus  blocking 
the  duodenal  orifice  of  the  ampulla  of  Vater  in  those  cases  where  the 
pancreatic  duct  opens  into  the  ampulla,  and  not  independently  upon 
the  wall  of  the  duodenum,  may  cause  the  stream  of  infected  bile  to 
be  diverted  into  the  pancreatic  duct  and  thus  set  up  just  such  an 
infectious  inflammatory  process.  The  condition  is  accompanied  by 
destruction  of  pancreatic  tissue,  and  as  a  result  the  pancreatic  juice 
is  able  to  escape  into  the  substance  of  the  pancreas  and  into  the  peri- 
toneal cavity,  producing  the  peculiar  phenomena  of  necrosis  of  the 
fatty  tissue  with  which  it  comes  in  contact  in  and  about  the  pancreas 
and  in  the  omentum,  mesentery,  subperitoneal  connective  tissue,  etc. 
This  secretion  also  carries  septic  agents  to  the  peritoneal  cavity  and 
is  capable  of  setting  up  a  peritonitis  which  is  fatal  unless  it  can 
be  controlled  by  the  surgeon.    The  diagnosis  in  these  cases  is  usually 

25 


386  ABDOMEN  AND  BACK. 

not  made  until  after  the  abdomen  has  been  opened.  The  operation 
is  usually  undertaken  with  the  idea  that  a  condition  of  intestinal 
obstruction  or  perforative  peritonitis  is  present  and  it  is  therefore 
rather  of  an  exploratory  nature. 

The  incision  is  best  placed  in  the  middle  line  above  the  umbilicus. 
When  the  abdomen  is  opened  the  peritoneal  cavity  is  usually  found 
containing  blood-stained,  purulent  fluid  and  the  omentum,  etc.,  marked 
by  small  patches  of  fat  necrosis  varying  in  size  from  a  pin-head  to  a 
pea  or  larger.  These  appearances  are  of  peculiar  significance  and 
should  direct  the  attention  of  the  operator  at  once  to  the  pancreas. 
After  the  abdomen  has  been  flushed  out  with  saline  solution  the  lesser 
peritoneal  cavity  should  be  entered.  An  incision  is  made  for  this 
purpose  in  the  gastro-colic  ligament.  Occasionally,  and  especially  if 
the  condition  has  existed  for  a  longer  time,  the  foramen  of  Winslow 
will  have  become  occluded  and  the  lesser  peritoneal  sac  will  be  found 
converted  into  a  large  abscess  cavity  filled  with  bloody,  purulent  fluid. 

Instead  of  proceeding  as  indicated  above,  the  median  exploratory 
incision  may  be  closed  and  the  abscess  cavity  opened  and  drained 
through  an  incision  in  the  left  lumbar  region;  or  through  an  incision 
that  commences  in  the  left  lumbar  region  near  the  tip  of  the  twelfth 
rib  and  which  is  carried  forward  parallel  with  and  a  short  distance 
away  from  the  free  border  of  the  ribs. 

In  all  cases  after  evacuating  the  abscess  and  thoroughly  flushing 
the  cavity  with  saline  solution  drainage  should  be  provided  in  the 
shape  of  a  large  glass  or  rubber  tube  surrounded  with  strip  gauze. 

The  incision  is  closed  for  part  of  its  extent  with  silk  sutures. 

For  Tumors. — New  growths  affecting  the  pancreas  primarily  are 
comparatively  rare.  Carcinoma,  adenoma,  and  sarcoma  have  been 
described.  Carcinoma  usually  affects  the  head  of  the  organ  and  may 
cause  obstructive  jaundice  by  compressing  the  common  bile-duct.  Tu- 
mors involving  the  tail  of  the  pancreas  may  be  treated  by  resection 
of  the  affected  portion  of  the  organ.  Diseased  portions  of  the  pancreas 
have  been  resected  during  the  course  of  operations  upon  the  stomach. 

The  abdomen  is  opened  through  an  incision  in  the  middle  line 
and  the  pancreas  reached  through  an  opening  in  the  gastro-hepatic  or 
gastro-colic  ligament  or  transverse  mesocolon.  Drainage  should  be 
provided  in  all  these  cases. 

Mikulicz  has  shown  that  the  mortality  is  much  greater  if  the  pan- 
creas is  injured  during  the  course  of  operations  upon  the  stomach. 
In  such  cases  drainage  is  desirable. 


SURGICAL  ANATOMY  OF  THE  SPLEEN.  387 

THE  SPLEEN. 

The  Surgical  Anatomy  of  the  Spleen. — The  spleen  is  a  solid 
organ  located  in  the  upper  left  part  of  the  abdomen  in  close  relation 
with  the  fundus  of  the  stomach,  to  which  it  is  attached  by  the  gastro- 
splenic  ligament  (omentum),  being  suspended  from  the  diaphragm 
by  the  phrenico-splenic  ligament,  its  lower  end  resting  upon  the 
phrenico-colic  ligament.  The  spleen  is  rather  ellipsoidal,  although 
its  shape  may  vary.  It  measures  usually  about  12  cm.  in  its  long 
diameter,  8  cm.  in  breadth,  and  3  cm.  in  thickness.  Its  size  may  vary 
considerably. 

Its  outer  surface  is  smooth  and  rounded,  and  looks  outward, 
upward,  and  backward  toward  the  diaphragm,  which  separates  it 
from  the  pleura  and  the  edge  of  the  lung  and  the  ninth,  tenth,  and 
eleventh  ribs.  Its  inner  surface  consists  of  two  areas :  the  anterior, 
the  gastric  surface,  which  is  the  broader,  looks  inward  and  forward, 
and  lies  close  to  the  posterior  surface  of  the  fundus  of  the  stomach; 
the  posterior  portion  of  the  inner  surface  is  in  contact  with  the  upper 
and  outer  part  of  the  left  kidney  and  the  tail  of  the  pancreas.  Be- 
tween these  two  areas  the  inner  surface  presents  the  hilum,  where 
the  vessels  and  nerves  pass  in  and  out  of  the  organ. 

The  lower  end  of  the  spleen  is  in  relation  with  the  splenic  flex- 
ure of  the  colon,  and  rests  upon  the  phrenico-colic  ligament,  which 
supports  it.  The  anterior  border  is  rather  sharp,  and  marked  by  a 
varying  number  of  notches,  usually  one.  Oftentimes  when  the  organ 
is  enlarged  the  anterior  notched  edge  can  be  made  out  by  palpation 
through  the  abdominal  wall.  The  posterior  border  is  rounded  and 
thick. 

The  splenic  artery  is  a  branch  of  the  coeliac  axis,  and  in  its 
course  to  the  hilum  of  the  spleen  runs  along  the  upper  border  of  the 
pancreas,  lying  above  the  splenic  vein.  The  splenic  vein  is  as  large 
around  as  one's  finger — twice  as  large  as  the  splenic  artery.  It 
emerges  in  several  branches  from  the  hilum  of  the  spleen,  runs  along 
the  upper  border  of  the  pancreas,  and  after  receiving  the  inferior 
mesenteric  vein  joins  with  the  superior  mesenteric  to  form  the  portal 
vein. 

The  spleen  is  almost  completely  invested  by  the  peritoneum, 
which  is  intimately  blended  with  the  firm  capsule  proper  of  the 
organ.  The  spleen  is  fixed  to  the  stomach  by  the  gastro-splenic 
ligament  (omentum)   and  to  the  diaphragm  by  the  phrenico-splenic 


388  ABDOMEN  AND  BACK. 

ligament,  the  suspensory  ligament.     Its  lower  end  rests  upon  the 
phrenico-colic  ligament. 

The  gastro-splenic  ligament,  or  omentum,  is  the  fold  of  peri- 
toneum which  is  reflected  from  the  fundus  of  the  stomach  over  to  the 
spleen,  and  between  its  layers  the  splenic  vessels  pass  to  and  from  the 
hilum  of  the  spleen  and  the  vasa  brevia  to  the  fundus  of  the  stomach. 
The  phrenico-splenic  ligament,  or  suspensory  ligament,  is  the  fold  of 
peritoneum  which  is  reflected  from  the  diaphragm  to  the  spleen. 

OPERATIONS  UPON  THE  SPLEEN. 

Splenotomy. — Incision  of  the  spleen  for  the  purpose  of  evacuat- 
ing and  draining  an  abscess  or  an  hydatid  cyst. 

The  abdominal  incision  may  vary  according  to  the  location  of  the 
tumor,  if  one  can  be  made  out.  A  vertical  incision  through  the  middle 
of  the  left  rectus  muscle  or  along  the  outer  edge  of  this  muscle  in  the 
linea  semilunaris  and  extending  from  the  costal  cartilages  downward 
for  a  distance  of  four  or  five  inches  may  be  employed;  or  an  oblique 
incision  below  and  parallel  with  the  left  costal  arch  may  be  made. 
The  operation  may  be  performed  in  one  or  two  sittings. 

In  One  Sitting. — After  the  spleen  has  been  exposed,  if  it  is 
found  adherent  to  the  parietal  peritoneum  it  may  be  incised  at  once 
and  packed  with  strip  gauze.  If  the  spleen  is  not  adherent  to  the 
abdominal  parietes  it  should  be  drawn  into  the  incision  and  steadied 
1  there  while  gauze  pads  are  packed  into  the  incision  and  about  the 
spleen  to  protect  the  peritoneal  cavity  from  soiling.  Fluid  under 
tension  should  be  drawn  off  as  nearly  completely  as  possible  with  the 
aspirator  so  as  to  avoid  flooding  when  the  organ  is  incised.  The 
spleen  is  freely  incised  and  the  edges  of  the  opening  thus  made  are 
sutured  to  the  edges  of  the  abdominal  incision.  The  abscess  or  cyst 
cavity  is  packed  with  strip  gauze  and  the  abdominal  incision  closed  in 
part  with  interrupted  sutures  of  silk,  each  suture  passing  through  the 
entire  thickness  of  the  abdominal  wall. 

In  Two  Sittings. — After  the  spleen  has  been  exposed  as  de- 
scribed above  it  is  fixed  to  the  edges  of  the  abdominal  incision  with 
several  catgut  sutures.  Each  suture  pierces  the  capsule  and  the 
substance  of  the  spleen  superficially  and  includes  the  parietal  perito- 
neum and  deep  muscle  layers  in  the  abdominal  incision.  Strip  gauze 
is  packed  through  the  incision  down  to  the  surface  of  the  spleen  and 
the  abdominal  incision  closed  in  part.    It  is  not  necessary  in  all  cases 


OPERATIONS  UPON  THE  SPLEEN.  389 

to  suture  the  exposed  spleen  to  the  edges  of  the  abdominal  incision.  It 
suffices  for  the  purpose  of  inducing  adhesion  between  the  spleen  and 
and  abdominal  wall  to  pack  strip  gauze  down  through  the  incision 
to  the  spleen. 

After  the  lapse  of  two  or  three  days,  adhesions  having  formed 
between  the  exposed  surface  of  the  spleen  and  the  abdominal  wall, 
the  abscess  or  cyst  may  be  incised  and  drained. 

Splenorrhaphy. — Suturing  of  wounds,  lacerations,  of  the  spleen 
for  the  purpose  of  controlling  hemorrhage.  Sutures  of  catgut  are  used 
and  should  take  a  broad  deep  bite.  They  tear  through  if  much  tension 
is  made.  It  would  probably  be  better  in  some  cases  of  hemorrhage  to 
extirpate  the  spleen. 

Splenopexy. — Fixation  of,  or  anchoring,  the  spleen.  This  op- 
eration is  performed  for  "wandering"  or  "floating"  spleen.  .If  the 
"floating"  spleen  is  more  than  twice  the  normal  size  or  if  diseased  it 
should  be  extirpated  rather  than  anchored.  One  method  of  fixation 
has  been  described  by  Bydygier  and  another  by  Bardenheuer. 

Bydygier's  Method. — The  abdomen  is  opened  through  an  in- 
cision in  the  middle  line,  commencing  near  the  ensiform  cartilage  and 
reaching  to  or  beyond  the  umbilicus;  or  an  incision  may  be  made 
through  the  middle  of  the  left  rectus  muscle.  Corresponding  as  nearly 
as  possible  to  the  normal  position  of  the  spleen,  ninth  to  eleventh  ribs, 
a  pocket  is  formed  in  the  parietal  peritoneum  by  making  a  transverse, 
slightly  curved  incision  with  the  convexity  upward  in  the  parietal 
peritoneum  and  then  tearing  the  peritoneum  loose  from  the  abdominal 
wall  to  an  extent  sufficient  to  make  a  pouch  that  will  accommodate  the 
lower  half  of  the  spleen.  The  spleen  is  placed  in  the  pouch  thus 
formed  and  secured  there  by  several  interrupted  sutures  that  unite  the 
free  edge  of  the  peritoneal  pouch  to  the  gastro-splenic  omentum.  In 
order  to  prevent  further  separation  of  the  peritoneum  and  the  spleen 
from  sinking  farther  into  the  peritoneal  pouch  one  or  two  silk  sutures 
are  introduced  through  the  parietal  peritoneum  and  the  deep  abdominal 
muscles.  These  sutures  are  applied  from  within  the  abdomen  and 
are  placed  just  below  the  bottom  of  the  peritoneal  pocket.  The  free, 
serous  surface  of  the  spleen  and  opposite  parietal  peritoneum  may  be 
vigorously  rubbed  with  a  gauze  wipe  to  induce  additional  adhesions. 
The  abdomen  is  closed  without  drainage. 

Bardexheuer's  Method. — The  incision  commences  near  the 
iliac  crest  and  extends  upward  in  the  mid-axillary  line  almost  as  far 
as  the  tenth  rib — about  10  cm.  long.    From  the  upper  end  of  this  in- 


390  ABDOMEN  AND  BACK. 

cision  a  second  one  is  made,  about  the  same  length,  extending  back- 
ward along  the  lower  border  of  the  tenth  rib.  The  incision  pene- 
trates all  the  layers  of  the  abdominal  wall  down  to,  but  not  through, 
the  parietal  peritoneum.  The  angular  flap  thus  outlined  is  reflected 
downward  and  the  parietal  peritoneum,  unopened,  is  exposed.  A  small 
incision  is  made  in  the  peritoneal  layer  and  the  spleen  secured  and 
drawn  out  through  it  edgewise  and  the  edges  of  the  opening  in  the 
peritoneum  fixed  all  around  to  the  pedicle  of  the  spleen,  gastro-splenic 
omentum,  with  interrupted  sutures  of  silk.  A  silk  thread  is  then 
passed  over  the  tenth  rib  and  through  the  lower  pole  of  the  spleen, 
but  this  is  not  tied  until  later.  Corresponding  to  the  lower  end  of  the 
spleen  several  silk  sutures  are  introduced  joining  the  deep  fascia  of 
the  reflected  abdominal  flap  to  the  subperitoneal  connective  tissue  in 
order  to  prevent  the  spleen,  later,  from  sinking  further  downward  be- 
tween the  peritoneum  and  abdominal  wall.  The  suspensory  suture 
which  was  thrown  over  the  tenth  rib  is  then  tied. 

The  abdominal  flap  is  replaced  and  sutured  accurately  layer  by 
layer  with  catgut.  The  suture  may  be  reinforced  with  a  number  of 
interrupted  silk  sutures  that  penetrate  through  the  skin,  fascia,  and 
divided  muscle. 

Splenectomy. — Extirpation  of  the  spleen. 

It  has  been  repeatedly  shown  that  extirpation  of  the  spleen  is 
not  followed  by  any  harmful  effect  upon  the  patient's  health. 

The  operation  is  done  for  wounds,  rupture,  prolapse;  tumors — 
cystic,  hydatid,  and  solid,  sarcoma;  wandering  spleen  if  much  en- 
larged or  diseased;   idiopathic  hypertrophy;   primary  tuberculosis. 

Incision  must  be  sufficiently  large.  It  may  be  placed  in  the 
middle  line,  reaching  from  near  the  ensiform  process  downward  to  or 
beyond  the  umbilicus.  As  a  rule,  better  access  is  had  through  an 
incision  penetrating  through  the  left  rectus  muscle  or  in  the  left 
linea  semilunaris.  It  may  be-  necessary  to  make  an  additional  trans- 
verse cut  outward  toward  the  flank  or  inward  through  the  body  of  the 
left  rectus  muscle  toward  the  middle  line.  Some  surgeons  advise  an 
oblique  incision  passing  downward  and  backward  below  and  parallel 
with  the  left  costal  arch. 

After  the  abdomen  has  been  opened  the  spleen  is  sought  for  and 
recognized.  If  adhesions  are  present  these  are  broken  up  bluntly  with 
the  fingers  or  if  they  are  thick  and  vascular  they  may  be  ligated  doubly 
and  cut.  In  freeing  the  spleen  the  operator  must  avoid  injuring  its 
capsule,  otherwise  there  may  be  much  troublesome  hemorrhage. 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  391 

After  the  spleen  has  been  separated  from  adhesions  it  is  drawn 
well  forward  into  the  incision.  This  effort  is  resisted  by  the  normal 
peritoneal  folds  that  connect  the  spleen  with  the  stomach,  gastro- 
splenic  omentum,  and  with  the  diaphragm,  phrenico-splenic  ligament. 
The  pedicle  of  the  spleen,  which  consists  practically  of  the  gastro- 
splenic  omentum  (including  the  splenic  vessels),  may  be  transfixed, 
through  its  middle,  with  a  curved,  blunt-pointed  ligature  carrier, 
provided  with  a  long  strand  of  strong  silk.  After  this  ligature  has 
been  placed  it  is  cut  so  as  to  make  two,  and  these  are  then  tied,  one 
including  the  upper  half  of  the  pedicle  and  the  other  the  lower  half. 
The  tail  of  the  pancreas  should  not  be  included  in  tying  these  ligatures. 
If  the  phrenico-splenic  ligament  is  not  already  included  in  the  liga- 
tures placed  as  described  this  structure  may  now  be  ligated  and  in 
a  similar  manner.  The  ligatures  should  be  tied  tight  and  left  long  to 
serve  as  tractors  in  order  to  pull  the  stump  of  the  pedicle  into  the 
wound  for  final  inspection  after  the  spleen  has  been  cut  away. 

The  pedicle  is  cut  close  to  the  spleen  and  the  organ  removed; 
the  stump  of  the  pedicle  may  be  drawn  gently  forward  and  an  effort 
made  to  isolate  and  ligate  the  splenic  artery  and  vein,  each  separately. 
If  the  pedicle  is  properly  secured  there  is  little  danger  of  subsequent 
hemorrhage.  After  the  spleen  has  been  removed  care  should  be 
taken  to  secure  any  remaining  bleeding  points. 

The  wound  in  the  abdomen  is  closed  without  drainage,  first  bring- 
ing the  edges  of  the  parietal  peritoneum  together  with  a  continuous 
catgut  suture  and  then  the  other  layers  with  interrupted  silk-worm  gut. 

OPERATIONS  UPON  THE  SPINAL  COLUMN. 

Laminectomy. — Eesection  of  the  lamina?  of  the  vertebras  for  the 
purpose  of  relieving  compression  of  the  cord  due  to  traumatism  or 
disease,  depressed  or  displaced  bone,  extravasated  blood,  pus,  tuber- 
culous products,  Pott's  disease,  tumors,  etc. 

The  patient  is  placed  prone  upon  the  table  with  a  shallow  cush- 
ion under  the  ribs  to  give  the  back  a  slight  curve.  A  long  incision 
is  made,  in  the  middle  line,  through  the  soft  parts  down  to  the  tips 
of  the  spinous  processes.  The  middle  of  this  incision  should  corre- 
spond to  the  probable  location  of  the  injury  or  disease. 

The  soft  parts — muscles,  etc. — upon  either  side  of  the  middle 
line  are  then  freely  separated  with  a  periosteum  elevator  so  as  to 
expose  the  lamina?  of  from  three  to  five  vertebra?. 


392  ABDOMEN  AND  BACK. 

Hemorrhage  should  be  controlled;  oozing,  by  temporary  press- 
ure of  a  pad,  etc.,  and  spurting  points  by  clamps  and  ligatures. 
The  spinous  processes  may  be  snipped  off  at  their  bases  with  the 
cutting  bone  forceps,  the  blades  of  which  may  be  conveniently  bent 
at  an  obtuse  angle. 

While  the  soft  parts,  detached  muscles,  etc.,  are  well  retracted, 
the  laminae,  if  not  already  fractured  by  a  traumatism,  are  divided 
and  then  removed. 

The  lamina?  that  are  to  be  resected  should  first  be  stripped  bare 
of  their  periosteum  and  any  remaining  soft  parts  with  the  sharp- 
edged  periosteum  elevator,  and  then  divided  as  close  as  possible  to 
the  transverse  processes,  first  on  one  side  and  then  on  the  other.    The 


Fig.  165.— Keen  Bone  Forceps.    The  end  of  the  upper  blade  is  fenestrated. 

division  of  the  laminae  may  be  accomplished  with  a  Hays  saw,  chisel, 
or  rongeur  forceps,  or  they  may  be  gnawed  through  with  a  Keen  or  a 
De  Vilbiss  forceps.  The  laminae  which  correspond  to  the  middle  of 
the  wound  are  first  resected  and  then  those  of  the  vertebrae  above 
and  below.  In  this  way  the  spinal  canal  is  opened  and  in  some  cases 
of  traumatism  the  compression — if  due  to  depressed  bone,  for  exam- 
ple— will  have  been  relieved. 

The  dura  mater  proper  may  be  exposed  by  tearing  with  a  blunt 
director  through  the  loose  connective  tissue  that  overlies  it.  In  thus 
exposing  the  dura  mater,  there  may  considerable  hemorrhage  from 
the  venous  plexus  that  is  located  in  the  posterior  part  of  the  vertebral 
canal  between  the  bony  wall  and  the  dura,  but  this  is  readily  controlled 
by  a  few  minutes'  compression  with  a  gauze  pad.  As  already  men- 
tioned, after  the  spinal  canal  has  been  opened,  the  immediate  cause  of 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  393 

the  symptoms  may  present  itself  and  the  condition  may  be  remedied 
without  opening  the  dura;  for  example,  a  dislocated  vertebra,  tuber- 
culous granulation  tissue,  extradural  tumor,  etc.  Prominent  angular 
deformity  of  the  anterior  wall  of  the  spinal  canal  due  to  fracture,  dis- 
location, Pott's  disease,  should  be  corrected  by  reduction  or  by  chiseling 
or  gouging  away  the  offending  process  of  bone;  carious  bone  may  be 
curetted  and  sequestra  removed. 

In  order  to  reach  the  anterior  wall  of  the  canal,  it  may  be  neces- 
sary to  divide  several  nerve-trunks  upon  one  side  and  lift  the  cord 
partly  out  of  its  bed.  The  severed  nerves  may  be  reunited  afterward 
by  suture. 

If  the  cause  of  the  symptoms  is  not  apparent  the  dura  should 
be  laid  open.  Before  opening  the  dura,  its  color,  degree  of  bulging, 
pulsation,  etc.,  should  be  noted.  The  dura  is  picked  up  with  a  toothed 
forceps  and  a  small  opening  made  in  the  middle  line,  and  through 
this  opening  the  dura  is  incised  upon  a  grooved  director  to  any 
requisite  length.  When  the  dura  is  incised  there  is  an  escape  of 
cerebro-spinal  fluid  and  may  be  pus  or  blood.  If  there  are  any  adhe- 
sions present  between  the  dura  mater  and  the  arachnoid  they  should 
be  gently  broken  up.  The  edges  of  the  dura  may  be  then  well  re- 
tracted and  the  cord  carefully  examined.  A  bent  probe  may  be  used 
for  the  purpose  of  investigating  the  sides  and  anterior  aspect  of  the 
cord. 

In  closing  the  wound  the  edges  of  the  dura  are  brought  together 
with  interrupted  catgut  sutures  placed  about  one-eighth  inch  apart, 
and  the  edges  of  the  muscles  and  skin  approximated  with  interrupted 
sutures  of  silk-worm  gut.  For  the  purpose  of  drainage,  a  narrow  strip 
of  gauze  is  introduced  into  the  bottom  of  the  wound,  its  extremity 
emerging  through  the  lower  end  of  the  skin  incision.  The  wound 
usually  heals  by  first  intention. 

The  parts  should  be  immobilized  by  incasing  the  patient  in  plaster 
or  by  the  use  of  a  proper  extension  apparatus. 

Lumbar  Puncture. — J.  Leonard  Corning,  of  New  York,  in  1885 
reported  experiments  of  injecting  solutions  of  cocain  into  the  spinal 
canal  through  a  puncture  in  the  dorsal  region  for  the  purpose  of  in- 
ducing analgesia,  etc. 

Quincke,  of  Kiel,  in  1891,  practiced  lumbar  puncture  for  the 
purpose  of  drawing  off  fluid  to  diminish  intracranial  pressure  in  cases 
of  hydrocephalus.  With  this  object  in  view  he  drew  off  as  much 
as  100  c.c.  in  some  cases. 


394  ABDOMEN  AND  BACK. 

Bier  in  1899  reported  a  number  of  cases  which  had  been  oper- 
ated upon  painlessly  under  the  influence  of  cocain  introduced  into 
the  subarachnoid  space  through  a  lumbar  puncture. 

Tuffier  in  1899  brought  the  matter  prominently  before  the  gen- 
eral profession,  and  since  then  the  method  has  been  practiced  by 
many  operators  with  varying  degrees  of  satisfaction. 

The  necessary  instruments  consist  of  a  needle  and  a  syringe. 
The  needle  should  be  about  10  cm.  long,  with  a  diameter  of  about 
1.1  mm.  and  with  a  canal,  or  bore,  of  0.8  mm.  The  point  of  the 
needle  should  be  sharp,  but  the  bevel  should  be  short.  The  needle 
throughout  may  be  made  of  steel  or  its  body  may  be  made  of  a  flex- 
ible alloy  and  its  extremity  of  steel.  Such  a  needle  will  bend  without 
breaking  (Bainbridge).  The  syringe  should  have  a  capacity  of  30 
minims,  and  be  so  constructed  as  to  permit  of  proper  sterilization;  a 
glass  barrel  with  a  solid  metal  piston  would  answer.  The  nozzle  of  the 
syringe  and  the  cap  of  the  needle  should  form  a  smooth  bevel  joint, — 
not  a  screw  thread, — in  order  to  permit  of  their  rapid  adjustment  and 
to  eliminate  the  use  of  washers. 

The  puncture  may  be  made  between  the  laminae  of  the  fourth 
and  fifth  lumbar  vertebrae  or  between  the  third  and  fourth  or  the 
fifth  and  first  sacral.  The  puncture  between  the  laminae  of  the  fourth 
and  fifth  seems  to  be  preferred  by  most  surgeons. 

The  needle  is  introduced  just  below  and  to  the  right  of  the  tip  of 
the  spinous  process  of  the  fourth  lumbar  vertebra  and  is  pushed  in  a 
direction  forward  and  inward  and  slightly  upward  into  the  spinal 
canal. 

The  patient  should  be  seated  upon  the  side  of  the  table  with 
his  back  to  the  operator,  his  trunk  bent  forward,  and  his  elbows  resting 
upon  the  thighs.  The  tips  of  the  spinous  processes  should  form  a 
straight  line  from  above  downward,  deviating  neither  to  the  right  nor 
left. 

To  locate  the  tip  of  the  spinous  process  of  the  fourth  lumbar 
vertebra,  which  is  the  guide  in  performing  the  operation,  a  line  may 
be  drawn  across  the  back  from  the  highest  point  of  one  iliac  crest 
to  a  corresponding  point  upon  the  other.  The  tip  of  the  spinous 
process  of  the  fourth  lumbar  will  be  found  to  correspond  to  this  line. 

The  patient  being  bent  forward  causes  the  space  between  the 
laminae  of  the  fourth  and  fifth  lumbar  vertebrae  to  become  wider. 
The  index  finger  of  the  left  hand  is  placed  upon  the  lower  part  of 
the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra,  and 


OPERATIONS  UPON  THE  SPINAL  COLUMN. 


)do 


with  the  right  hand  the  needle  is  introduced;  it  is  entered  just 
below  and  about  1  cm.  to  the  right  of  this  point  (tip  of  the  spine  of 
the  fourth  lumbar).  The  skin  may  be  anaesthetized  and  a  small  in- 
cision made  with  the  point  of  the  knife  in  order  to  permit  the  easy- 
passage  of   the  needle   through   this   structure,   which  is   sometimes 


Fig.  166. — Lumbar  Puncture.  Tip  of  spinous  process  of  fourth  lumbar 
vertebra  corresponds  to  a  line  drawn  across  the  back  touching  the  highest 
point  of  each  iliac  crest.  The  needle  is  inserted  just  below  and  to  right  of 
the  tip  of  the  spinous  process  of  the   fourth  lumbar  vertebra. 

pretty  tough  and  difficult  to  penetrate.  The  needle  is  then  pushed 
slowly  and  deliberately  forward  and  inward  through  the  soft  parts, 
entering  the  spinal  canal  in  the  middle  line  between  the  lamina?  of 
the  fourth  and  fifth  lumbar  vertebra?.  After  the  needle  has  passed 
through  the  ligament  between  the  laminae,  ligamentum  subflavuni, 
and  the  dura  mater  into  the  subarachnoid  space  there  is  felt  a  sense 


396  ABDOMEN  AND  BACK. 

of  diminished  resistance  which  is  readily  appreciated,  especially  by 
the  experienced.  The  positive  proof  that  the  extremity  of  the  needle 
is  in  the  subarachnoid  space  is  the  escape  of  the  clear  cerebro-spinal 
fluid,  which  flows  from  the  end  of  the  needle  drop  by  drop.  Not  more 
than  about  ten  drops  of  the  cerebro-spinal  fluid  should  be  allowed  to 
escape.  The  syringe  containing  the  cocain  solution  which  is  to  be 
introduced  is  now  adjusted  to  the  needle  and  its  contents  slowly  in- 
jected. From  15  to  20  minims  of  a  2-per-cent.  solution  is  the  quan- 
tity usually  injected. 

Unless  the  escape  of  the  cerebro-spinal  fluid  occurs  to  indicate 
positively  that  the  end  of  the  needle  is  in  the  subarachnoid  space  the 
injection  should  not  be  made. 

If  the  needle  strikes  an  impediment,  bone,  on  the  way,  it  should 
be  partly  withdrawn  and  its  direction  changed  so  as  to  avoid  the 
obstruction.  One  should  not  attempt  to  forcibly  change  the  course 
of  the  needle  by  bending  it  without  withdrawing  it  at  least  in  part, 
as  it  may  break  off;  a  sudden  movement  or  jerk  on  the  part  of  the 
patient  may  also  break  the  needle. 


PART  VI. 

THE  RECTUM. 


Surgical  Anatomy  of  the  Rectum.  —  The  rectum  is  the  ter- 
mination of  the  alimentary  canal  and  is  contained  within  the  true 
pelvis,  the  posterior  wall  of  which  is  formed  hy  the  sacrum  and 
coccyx. 

The  Sacrum  is  an  irregular,  triangular-shaped  bone  formed 
by  the  coalescence  of  five  vertebras.  With  the  coccyx  it  forms  the 
lower  part  of  the  vertebral  column  and  the  posterior  wall  of  the 
pelvis,  where  it  is  wedged  in  between  the  ossa  innominata. 

It  is  flattened  from  before  backward  and  curved  upon  itself, 
and  is  placed  very  obliquely,  so  that  its  anterior  surface  looks  down- 
ward as  well  as  forward.  Above,  it  articulates  with  the  fifth  lumbar 
vertebra,  forming  a  prominent  angle  which  projects  forward  and 
forms  the  back  part  of  the  inlet  into  the  true  pelvis.  Its  lower  end 
articulates  with  the  base  of  the  coccyx.  The  lateral  borders  of  the 
sacrum  are  broad  and  irregular  above,  for  articulation  with  the  iliac 
bones  and  for  the  attachment  of  the  posterior  sacro-iliac  ligaments. 
The  lower  part  of  the  lateral  border  is  thin,  and  gives  attachment 
to  the  greater  and  lesser  sacro-sciatic  ligaments  and  to  a  portion  of 
the  gluteus  maximus  muscle.  Its  anterior  surface  is  smooth,  con- 
cave, looks  downward  and  forward,  and  presents  on  either  side,  one 
below  the  other,  the  four  anterior  sacral  foramina,  through  which 
openings  the  anterior  sacral  nerves  escape  from  the  sacral  canal. 
The  branches  which  emerge  from  the  first,  second,  and  third  ante- 
rior sacral  foramina  are  large  and  go  to  form  the  sacral  plexus. 
Through  the  fourth  anterior  sacral  foramina  emerge  nerves  which 
are  distributed  to  the  rectum  and  the  bladder. 

The  posterior  surface  of  the  sacrum  is  convex,  rough,  and  irreg- 
ular. In  the  middle  line  from  above  downward  are  three  or  four 
tubercles,  which  represent  the  corresponding  spinous  processes; 
usually  the  fourth  and  always  the  fifth  are  absent.  External  to  the 
spinous  processes,  on  either  side  of  the  middle  line,  are  the  four 
posterior  sacral  foramina,  one  below  the  other.  These  provide  exit 
to  the  posterior  sacral  nerves,  which  are  of  no  importance  surgically. 
Between  the  posterior  sacral  foramina  and  the  spinous  processes  the 

(397) 


398  RECTUM. 

bone  is  smooth,  and  corresponds  to  the  laminae  of  the  other  verte- 
bras, forming  the  posterior  wall  of  the  sacral  canal;  the  laminae  of 
the  fourth  usually  and  of  the  fifth  always  are  absent,  thus  leav- 
ing the  sacral  canal  open  at  its  lower  part.  The  margins  of  the 
laminae  below,  where  the  canal  is  open,  are  prominent,  and  are  called 
the  cornua.  They  articulate  with  the  corresponding  cornua  of  the 
coccyx.  The  posterior  surface  of  the  sacrum  is  covered  by  and  gives 
attachment  to  the  erector  spinae  muscle. 

The  Coccyx  is  formed  of  four  rudimentary  vertebrae,  and  con- 
tains no  spinal  canal.  Below,  at  the  tip,  the  coccyx  is  pointed  and 
gives  attachment  to  the  sphincter  ani.  Above,  it  presents  a  base 
with  a  prominent  process  on  each  side,  the  cornu.  Its  base  artic- 
ulates with  the  lower  end  of  the  sacrum;  its  cornua  articulate  with 
those  of  the  sacrum.  Its  lateral  border  gives  attachment  to  the 
greater  and  lesser  sacro-sciatic  ligaments,  to  the  coccygeus  muscle, 
and  low  down  near  its  tip  to  a  few  fibers  of  the  levator  ani  muscle. 

The  Rectum  is  continuous  with  the  sigmoid  flexure  and  ter- 
minates at  the  anus.  It  is  about  eight  inches  long,  and  is  located  in 
the  back  part  of  the  true  pelvis,  surrounded  by  loose  connective 
tissue.  It  includes  that  part  of  the  large  intestine  which  reaches 
from  the  left  sacro-iliac  synchondrosis  to  the  anus.  It  is  usually 
described  as  consisting  of  three  parts. 

The  first,  or  upper,  part  of  the  rectum  extends  from  the  left 
sacro-iliac  synchondrosis  toward  the  middle  line,  and,  dipping  into 
the  pelvis  in  front  of  the  sacrum,  becomes  continuous,  opposite  the 
second  sacral  vertebra,  with  the  second,  or  middle  part.  This  upper 
part  of  the  rectum  is  narrower  than  the  middle  portion,  and  com- 
prises about  one-half  its  entire  length.  It  is  provided  with  a  com- 
plete investment  of  peritoneum,  which,  as  mesorectum,  is  attached 
to  the  front  of  the  sacrum,  and  thus  serves  to  suspend  the  rectum  in 
the  pelvis.  Dipping  down  into  the  pelvis,  behind  the  rectum,  be- 
tween the  folds  of  the  mesorectum,  is  the  termination  of  the  inferior 
mesenteric  artery,  which  is  known  as  the  superior  hemorrhoidal. 
This  part  of  the  rectum  is  in  relation  behind  with  the  left  sacro- 
iliac synchondrosis  and  the  front  of  the  sacrum.  Interposed  be- 
tween it  and  the  sacrum  are  the  pyriformis  muscle,  the  sacral  plexus 
of  nerves,  and  the  left  internal  iliac  vessels  and  their  branches. 
Anteriorly  it  is  covered  by  the  peritoneum,  and  is  in  relation  with 
some  coils  of  small  intestine. 

The  second,  or  middle,  part  of  the  rectum  is  more  roomy  than 


SURGICAL  ANATOMY  OF  THE  RECTUM.  399 

the  first  part,  and  is  known  as  the  ampulla;  it  corresponds  to  the 
front  of  the  sacrum  and  coccyx,  reaching  from  the  second  sacral 
vertebra  to  the  tip  of  the  coccyx.  It  is  curved,  with  its  concavity 
forward.  This  part  of  the  rectum  is  covered  only  upon  its  anterior 
aspect  by  the  peritoneum.  In  the  male  the  peritoneum  is  reflected 
from  this  part  of  the  rectum  forward  on  to  the  bladder,  which  it 
reaches  just  above  the  seminal  vesicles  (see  Fig.  210).  In  the  female 
the  peritoneum  reaches  lower  down  upon  the  front  surface  of  the 
rectum  than  in  the  male,  and  is  reflected  from  this  organ  forward 
upon  the  upper  fourth  of  the  posterior  wall  of  the  vagina  and  upon 
the  uterus,  forming  the  pouch  of  Douglas.  This  pouch  often  con- 
tains coils  of  small  intestine  and  in  the  female  may  contain  a  dis- 
placed ovary. 

In  the  male  the  lower  part  of  this  middle  portion  of  the  rectum 
is  in  relation  with  the  base,  or  trigone,  of  the  bladder,  the  latter 
lying  directly  in  front  of  the  rectum.  Between  the  base  of  the 
bladder  and  this  part  of  the  rectum  are  the  seminal  vesicles  and  the 
prostate  gland,  and  here  upon  either  side  the  ureters  enter  the 
bladder.  In  the  female  the  lower  portion  of  this  part  of  the  rectum 
is  in  relation  with  the  posterior  wall  of  the  vagina. 

The  third,  or  lowest,  part  of  the  rectum  is  that  portion  which 
extends  from  the  tip  of  the  coccyx  to  the  anus,  and  is  directed  down- 
ward and  backward;  it  has  no  relation  whatever  with  the  peritoneal 
cavity.  In  the  male  the  perineum  separates  this  third  portion  of 
the  rectum  from  the  urethral  canal,  and  in  the  female  from  the 
lower  part  of  the  vagina.  This  part  of  the  rectum  is  rather  narrow, 
and  corresponds  to  the  location  of  the  sphincters.  Upon  either  side 
of  this  part  of  the  rectum,  the  levator  ani,  which  extends  downward 
and  inward  from  its  origin  along  the  lateral  wall  of  the  true  pelvis, 
is  attached. 

Besides  the  antero-posterior  curves  already  described  the  rec- 
tum presents  a  lateral  curve.  The  first  part  of  the  rectum  in  dipping 
into  the  pelvis  from  the  left  sacro-iliac  synchondrosis  reaches  a 
little  to  the  right  of  the  middle  line,  while  the  lower  part  lies  a 
little  to  the  left  of  the  middle  line. 

The  lumen  of  the  rectum  presents  three  half-moon  folds,  or 
plicae  sigmoidea,  with  corresponding  constrictions  on  its  outer  surface. 
These  folds  contain  muscular  fibers.  The  most  marked  and  constant 
of  these  folds,  plica  transversalis  recti,  is  located  about  half-way  up 
upon  the  right  wall,  5  to  6  cm.  from  the  anal  orifice  and  upon  a 


400  RECTUM. 

level  with  Douglas's  fold.  The  two  others  are  upon  the  left  wall, 
not  so  constant  nor  so  prominent,  and  are  placed  one  nearer  and  the 
other  farther  away  from  the  anus  than  the  one  first  mentioned. 
These  folds  may  offer  considerable  obstruction  to  the  passage  on- 
ward of  bougies,  etc. 

In  the  lower  part  of  the  rectum  the  mucous  membrane  is 
thrown  into  longitudinal  folds, — columnag  Morgagni, — so  that  upon 
section  it  would  present  a  star-shaped  appearance.  About  one  inch 
above  the  anal  opening  the  circular  muscular  fibers  are  increased 
in  number  and  aggregated  into  a  bundle — the  sphincter  internus; 
this  is  composed  of  unstriped  muscular  fibers. 

Surrounding  the  anal  orifice  and  attached  behind  to  the  tip  of 
the  coccyx  and  in  front  to  the  midpoint  of  the  perineum  is  the  col- 
lection of  muscular  fibers  which  is  known  as  the  sphincter  externus; 
this  is  formed  of  striped  voluntary  muscular  fibers. 

The  skin  about  the  anus  is  thrown  into  folds,  which  radiate 
toward  the  anus,  and  often  in  the  form  of  tags,  etc.,  may  become 
hypertrophied,  inflamed,  and  itch — external,  or  itching,  piles;  or 
they  may  present  cracks  and  fissures  between  them,  at  the  edge  of 
the  anus — fissure  in  ano. 

The  rectum  is  supplied  by  the  superior  hemorrhoidal  artery, 
the  termination  of  the  inferior  mesenteric.  This  vessel  descends 
behind  the  rectum  between  the  folds  of  the  mesorectum,  and  op- 
posite the  middle  of  the  rectum  divides  into  two  branches;  these 
distribute  branches  upon  the  sides  of  the  rectum  almost  to  the  lower 
end.  One  may  cut  into  the  posterior  wall  of  the  rectum  (strictures, 
etc.)  for  a  distance  of  about  three  inches  above  the  anal  orifice  with- 
out meeting  this  vessel.    It  bifurcates  above  this  point. 

The  middle  hemorrhoidal  branches  are  derived  from  the  in- 
ternal iliac.  The  inferior  hemorrhoidal,  several  on  each  side,  are 
derived  from  the  internal  pudic  (branch  of  the  internal  iliac)  as  it 
courses  forward  upon  the  inner  aspect  of  the  tuber  ischii;  they  pass 
inward  toward  the  anus  and  beneath  the  skin,  and  supply  the  in- 
tegument about  the  anus  and  the  lower  end  of  the  rectum;  these 
branches  are  divided  when  incisions  are  made  in  this  region  in  the 
skin  or  into  the  ischio-rectal  fossag.  The  branches  from  these  three 
sets  of  vessels  anastomose  freely  with  each  other  up  and  down  the 
rectum. 

The  veins  of  the  rectum  form  a  plexus  of  interanastomosing 
branches  upon  the  wall  of  the  rectum;  they  terminate  above  in  the 


OPERATIONS  UPON  THE  RECTUM.  401 

superior  hemorrhoidal,  which  empties  into  the  inferior  mesenteric, 
which  in  turn  empties  into  the  portal.  The  middle  and  inferior 
hemorrhoidal  veins  empty,  the  middle  into  the  internal  iliac  and  the 
inferior  into  the  internal  pudic.  Thus  the  rectum  is  liberally  sup- 
plied with  arterial  hlood  from  both  the  inferior  mesenteric  and  the 
internal  iliac  arteries,  the  branches  from  both  freely  anastomosing 
with  each  other;  it  is  drained  by  venous  branches  which  carry  blood 
to  both  the  portal  and  general  circulation,  these  also  freely  inter- 
communicating with  each  other. 

The  venous  plexus  situated  in  the  lower  part  of  the  rectum, 
just  above  the  anus  and  beneath  the  mucous  membrane,  is  tortuous, 
and  in  certain  conditions — disturbance  of  the  portal  circulation, 
habitual  constipation,  pressure  of  the  gravid  uterus,  etc. — may  be- 
come enlarged,  pouched,  and  varicose,  and  give  rise  to  the  condition 
known  as  "bleeding  piles,"  or  internal  hemorrhoids.  Through  the 
veins  which  drain  the  rectum  infection  may  be  carried  to  the  liver 
— abscess  of  the  liver,  etc. 

The  nerves  that  emerge  from  the  first,  second,  and  third  ante- 
rior sacral  foramina  join  with  each  other  to  form  the  sacral  plexus. 
The  rectum  is  supplied  by  nerves  that  emerge  through  the  fourth 
anterior  sacral  foramen.  Branches  from  these  nerves  are  also  dis- 
tributed to  the  bladder. 


OPERATIONS  UPON  THE  RECTUM. 

Dilatation  of  the  Sphincter. — This  operation  is  practiced  as  a 
curative  measure  for  fissure  in  ano  and  as  a  preliminary  step  in  other 
operations  upon  the  anus  and  rectum. 

The  patient  is  placed  in  the  lithotomy  position.  Under  anaes- 
thesia two  fingers  or  the  thumb  of  each  hand  are  introduced  through 
the  anus  and  well  up  into  the  rectum  beyond  the  level  of  the  internal 
sphincter,  and  a  gradually  increasing  steady  force  is  exerted  in  a 
lateral  direction  toward  either  tuber  ischii  until  the  sphincter  is 
thoroughly  relaxed.  Considerable  force  may  be  employed,  but  it 
should  be  applied  gradually,  and  not  abruptly. 

Fistula  in  Ano. — This  may  be  either  complete  or  incomplete. 
The  incomplete  may  be  either  blind  external  or  blind  internal. 

A  complete  fistula  is  a  tract,  or  sinus,  which  opens  internally 
into  the  rectum  and  externally  upon  the  skin  near  the  margin  of 
the  anus,  and  may  allow  the  escape  of  gas  and  fasces  from  the  bowel. 


402 


RECTUM. 


The  opening  into  the  rectum  is  usually  single,  but  there  may  be 
several  openings  upon  the  skin. 

If  the  finger  is  introduced  into  the  rectum  and  a  probe  passed 
into  the  fistula  through  the  opening  in  the  skin,  its  point  may  be 
felt  beneath  the  rectal  mucous  membrane  and  may  be  guided 
through  the  inner  orifice  of  the  fistula  into  the  rectum.  This  open- 
ing will  be  found  a  variable  distance  above  the  anal  orifice  and  at 
times  may  be  somewhat  difficult  to  discover;  it  may  be  located  above 
the  internal  sphincter  or  it  may  be  just  above  the  external  sphincter 
close  to  the  margin  of  the  anus. 

An  incomplete,  or  blind,  fistula  is  one  which  presents  an  orifice 
at  only  one  end.     If  it  opens  into  the  rectum,  but  not  externally 


Fig.  168.— Blind  Internal 
Fistula.  Arrow  indicates 
opening  from  rectum.  For 
letters,  see  Fig.  167. 


Fig.  169.— Blind  External 
Fistula.  Arrow  shows  open- 
ing upon  the  skin.  For 
letters,  see  Fig.  167. 


Fig.  167.— Complete  Fist- 
ula in  Ano.  M,  muscular 
layer  of  the  rectum;  MM. 
mucous  membrane  layer  of 
rectum;  ISE,  cross  section 
of  external  sphincter;  SI, 
cross  section  of  internal 
sphincter. 


upon  the  skin,  it  is  called  a  blind  internal  fistula;  if  it  opens  ex- 
ternally upon  the  skin,  but  not  internally  into  the  rectum,  it  is  called 
a  blind  external  fistula. 

Operation  foe  Complete  Fistula. — The  anus  is  first  thor- 
oughly stretched.  The  finger  is  then  introduced  into  the  rectum 
and  a  blunt-pointed  grooved  director  passed  into  the  fistula  through 
the  opening  in  the  skin.  The  point  of  the  director,  which  may  be 
recognized  by  the  finger  in  the  rectum  beneath  the  rectal  mucous 
membrane,  is  guided  into  the  bowel  through  the  internal  orifice  of- 
the  fistula.  It  is  important  to  find  this  opening.  The  end  of  the 
director  is  then  brought  out  through  the  anus, — the  director  may 
be  bent  somewhat  in  order  to  do  this, — and  the  bridge  of  tissue 
upon  the  director  is  divided  with  the  knife,  carried  along  the  groove 


OPERATIONS   UPON   THE   RECTUM.  403 

of  the  director;  the  fistula  is  thus  laid  open  through  its  whole 
length  into  the  rectum.  If  there  is  more  than  one  external  orifice 
upon  the  skin,  the  intervening  tissue  between  the  separate  open- 
ings should  be  divided.  Any  secondary  sinuses  branching  off 
from  the  main  fistulous  tract  should  also  be  laid  open.  As  the  in- 
ternal orifice  of  the  fistula  is  above  the  external  sphincter  or  may 
be  above  the  internal  sphincter,  these  muscles  are  naturally  divided 
when  the  fistula  is  laid  open.  One  may  curette  the  tract  of  the  sinus 
after  it  has  been  laid  open,  but  too  much  force  should  not  be  used. 
The  whole  wound  is  finally  packed  with  iodoform  gauze.  This  pack- 
ing should  not  be  too  tight,  but  should  reach  well  to  the  bottom  of 
the  wound  in  every  direction.  The  bleeding  is  usually  readily  con- 
trolled by  the  packing.  Any  spurting  vessels  should  be  clamped  and 
tied  or  the  clamps  may  be  left  on  until  the  first  dressing. 

Operation  foe  Incomplete  Fistula  is  practically  the  same 
as  the  foregoing.  If  there  is  no  opening  into  the  rectum, — a  blind 
external  fistula, — the  point  of  the  director,  which  is  passed  into  the 
fistula  through  the  external  orifice  and  which  is  felt  beneath  the 
rectal  mucous  membrane  by  the  finger  within  the  rectum,  may  be 
forced  into  the  rectum,  the  sinus  being  thus  converted  into  a  com- 
plete fistula,  and  the  parts  then  divided  as  already  described. 

If  there  is  no  external  opening, — a  blind  internal  fistula, — we 
make  one.  The  skin  about  the  margin  of  the  anus  at  the  point 
corresponding  to  the  blind  external  extremity  of  the  fistulous  tract 
is  usually  marked  by  redness,  induration,  etc.  After  the  skin  has 
been  incised  at  this  point,  thus  converting  the  sinus  into  a  com- 
plete fistula,  it  is  treated  as  above  described. 

Hemorrhoids.  External,  or  Itching,  Piles  present  them- 
selves about  the  margin  of  the  anal  orifice  outside,  external  to  the 
sphincter;  they  consist  of  cutaneous  tags,  which  may  be  snipped 
off  with  the  scissors,  the  edges  of  the  skin  being  then,  if  necessary, 
brought  together  with  a  single  suture.  Occasionally  they  contain 
a  varicosed  vein,  which  may  be  thrombosed;  this  may  be  laid  open, 
the  clot  turned  out,  and  the  edges  of  the  skin  brought  together  with 
one  or  two  catgut  stitches. 

Frequently  a  fissure  is  located  at  the  base  of  one  of  these  ex- 
ternal tags,  or  piles,  and  it  is  therefore  wise,  in  all  these  cases,  to 
stretch  the  sphincter  before  removing  the  pile. 

Internal,  or  Bleeding,  Piles. — These  are  located  entirely 
within  the  anus,  only  appearing  externally  when  the  patient  strains, 


404 


RECTUM. 


or  bears  down.  They  may  be  caught  in  the  grasp  of  the  sphincter 
and  become  strangulated.  When  the  patient  strains  they  may  ap- 
pear as  one  or  more  fairly  well  defined  bunches.  Each  mass  consists 
of  a  bunch  of  dilated,  pouched,  varicose  veins  covered  over  by  mu- 
cous membrane  which  may  be  normal  in  appearance  or  may  be  more 
or  less  ulcerated. 

Ligation  and  Excision. — The  sphincter  is  first  stretched  and 
the  rectum  thoroughly  irrigated.  Each  individual  hemorrhoidal 
mass  is  then  seized  with  a  clamp,  an  ordinary  artery  forceps,  and 
while  it  is  pulled  down  the  mucous  membrane  around  its  base  is  cut 
through  by  snipping  with  the  blunt-pointed  scissors.  This  incision 
6hould  extend  through  the  mucous  membrane  into  the  submucous 


Fig.  170.— Hemorrhoids.  E,  hemorrhoidal  mass  (internal  piles),  consist- 
ing of  a  bunch  of  tortuous  veins  covered  by  mucous  membrane  protruding 
through  the  anal  orifice;  M,  muscular  layer  of  the  rectum;  M.M.,  mucous 
membrane  layer  of  rectum;  SE,  cross  section  of  external  sphincter  muscle; 
SI,  cross  section  of  internal  sphincter  muscle;  8M,  submucous  layer  in  which 
the  veins  ramify;  *,  loose  connective  tissue  to  either  side  of  lower  end  of 
rectum  in  ischio-rectal  fossa. 


connective  tissue  layer,  but  should  not  cut  into  the  vessels  that  go 
to  form  the  hemorrhoidal  mass.  After  this  the  mucous  membrane 
at  the  base  of  the  pile  may  be  peeled  back  with  the  finger-nail  or 
the  end  of  the  scissors,  and  the  base  or  pedicle  of  the  pile  surrounded 
with  a  strong  catgut  ligature;  this  should  be  tied  very  tight  so  that 
it  cannot  slip  (No.  2  plain  catgut).  The  pile  is  cut  away  close  to 
the  ligature  and  the  ligature  then  cut  short.  Each  hemorrhoidal 
mass  that  presents  itself  is  treated  in  like  manner.  They  usually 
vary  from  two  to  four  in  number.  The  edges  of  each  opening  may 
be  brought  together  over  the  stump  of  the  pile  with  one  or  two  cat- 
gut sutures,  but  this  is  probably,  in  most  cases,  unnecessary. 

After  the  operation  has  been  completed  strip  gauze  is  packed 


OPERATIONS   UPON"  THE   RECTUM.  405 

into  the  rectum  fairly  tight.  It  should  reach  to  a  point  above  the 
level  of  the  site  of  the  operation.  Instead  of  the  strip  gauze  one 
may  introduce  a  tampon  in  the  shape  of  a  square  piece  of  gauze,  the 
center  of  which  is  seized  with  a  forceps  and,  pouch-like,  pushed  into 
the  rectum  beyond  the  site  of  the  operation,  and  then  into  this  gauze 
pouch  strips  of  gauze  or  a  wad  of  cotton  may  be  packed.  The  pack- 
ing is  to  guard  against  hemorrhage  from  the  slipping  of  a  faulty 
ligature.  One  should  bear  in  mind  that  the  patient  may  suffer  con- 
siderable hemorrhage  into  the  bowel  without  any  blood  appearing 
externally;    hence  the  importance  of  carefully  tamponing. 

Clamp  and  Cautery. — After  the  anus  has  been  stretched,  etc., 
each  pile  is  seized  at  its  most  prominent  part  with  an  artery  forceps 
and  drawn  well  down  and  a  special  clamp — pile  clamp — applied  to 
its  base.  The  end  of  the  clamp  as  it  grasps  the  pile  should  be  di- 
rected upward  into  the  rectum;  i.e.,  it  should  not  grasp  the  hemor- 
rhoidal mass  along  a  line  parallel  with  the  margin  of  the  anus,  as 
this  would  result  in  an  annular  scar,  which  is  not  desirable.  The  pile 
should  be  firmly  caught  between  the  blades  of  the  clamp  and  secured 
by  turning  the  screw  down  tight.  The  pile  is  then  cut  away  with 
the  scissors,  rather  close  to,  but  not  flush  with,  the  surface  of  the 
blades  of  the  clamp;  a  small  part  of  the  tissue  should  be  left  pro- 
truding beyond  the  surface  of  the  clamp  after  the  pile  is  cut  away. 
The  cautery  at  a  red  heat  is  now  applied  to  the  cut  edge  of  the  re- 
maining portion  of  the  pile  which  protrudes  beyond  the  surface  of 
the  blades  of  the  clamp  and  this  is  slowly  burned  to  a  crisp  down  to 
the  surface  of  the  blades.  The  clamp  is  then  removed.  Each  pile 
is  treated  in  this  manner.    It  is  unnecessary  to  tampon  the  rectum. 

Excision  of  a  Circumscribed  Part  of  the  Rectal  Wall. — Before 
proceeding  with  this  operation  the  bowel  should  be  thoroughly  emp- 
tied by  a  course  of  laxatives  and  thorough  irrigation  of  the  rectum. 
This  preparatory  treatment  may  well  occupy  several  days  to  a  week. 
The  ease  with  which  a  limited  portion  of  the  rectal  wall  is  excised 
depends  upon  the  situation  of  the  disease. 

If  the  Disease  Involves  the  Lower  Part  of  the  Bowel 
situated  at  or  near  the  anus,  the  operation  is  comparatively  easy. 
The  sphincter  is  first  thoroughly  stretched  so  that  it  is  completely 
relaxed.  The  tumor  or  diseased  area  is  seized  with  a  vulsella  forceps 
or  the  fingers  and  is  drawn  down  and  out  through  the  anal  orifice, 
and  may  then  be  excised,  together  with  that  part  of  the  rectal  wall 
which  forms  its  base,  with  the  scissors  or  a  sharp  knife.     The  hem- 


406  EECTUM. 

orrhage  should  be  controlled,  seizing  or  tying  bleeding  points  as  they 
are  encountered,  and  the  edges  of  the  defect  in  the  rectal  wall 
brought  together  by  suture  step  by  step  as  the  operation  progresses. 
The  wound  in  the  rectal  wall  should  be  closed  in  a  transverse  direc- 
tion, because  if  sewed  in  a  vertical  line  we  may  get  a  troublesome 
diminution  of  the  caliber  of  the  bowel,  and  this  should  be  avoided  in 
this  narrow  part.  The  stitches  should  be  of  catgut  and  interrupted, 
and  should  pass  through  the  whole  thickness  of  the  wall  of  the  bowel; 
the  ends  of  the  sutures  should  be  left  long  to  serve  as  tractors  to 
facilitate  the  placing  of  the  succeeding  sutures.  After  the  diseased 
part  has  been  entirely  removed  additional  sutures  may  be  placed 
between  those  already  introduced,  but  these  should  pass  only  through 
the  mucous  and  submucous  layers  of  the  bowel,  and  are  for  the  pur- 
pose of  giving  a  more  exact  union  of  the  edges  of  the  mucous  mem- 
brane. 

If  the  Disease  is  Located  Higher  up,  Beyond  the  Region 
or  the  Anus. — The  field  of  operation  must  be  made  accessible  to 
view  and  touch,  if  possible;  but  this  is  more  difficult  than  is  the  case 
when  the  disease  is  located  lower  down,  nearer  the  anus. 

The  sphincter  should  be  forcibly  dilated,  so  that  it  is  entirely 
relaxed.  The  tumor  or  diseased  area  may  then  be  seized  with  a 
vulsella  forceps,  and  can  often  be  pulled  down  and  out  through  the 
anal  orifice,  under  which  circumstances  the  operation  may  be  done 
practically  as  described  for  disease  situated  lower  down,  in  the  anal 
region.  Usually,  however,  the  stretching  of  the  anal  orifice  does  not 
suffice  to  allow  access  to  the  diseased  area,  and  we  may  find  it  de- 
sirable to  make  an  incision,  from  within  the  bowel,  through  the 
posterior  wall  of  the  rectum,  including  the  anus,  back  to  the  coccyx. 
In  this  way  we  may  make  the  field  of  operation  accessible.  Occa- 
sionally, however,  even  with  this  posterior  incision,  we  are  still  un- 
able to  bring  the  disease  within  easy  reach,  or  we  may  wish  to  avoid 
this  posterior  incision.  Under  these  circumstances  the  work  must 
be  done  within  the  rectum  with  the  aid  of  retractors.  For  this  pur- 
pose, after  the  sphincter  has  been  thoroughly  dilated,  two  flat-bladed 
retractors  are  introduced  well  up  into  the  rectum,  one  on  either  side, 
the  mucous  membrane  that  tends  to  prolapse  between  the  blades  of 
the  retractors  being  held  back  with  a  pad  upon  a  long  sponge  holder. 
One  should  thus  be  able  to  see  the  field  of  operation,  and  this  is  nec- 
essary in  order  to  control  the  hemorrhage  and  to  suture  the  edges 
of  the  wound  which  is  left  in  the  rectal  wall  after  the  diseased  por- 


OPERATIONS  UPON  THE  RECTUM.  407 

tion  has  been  extirpated.  The  retractors  being  in  position,  the  dis- 
eased area  is  seized  with  a  volsella  forceps  and  excised  as  already  de- 
scribed. The  portion  of  the  rectum  immediately  above  the  anal 
region  is  roomy,  and  one  may  suture  the  wound  left  in  this  part  of 
the  rectal  wall,  after  the  excision  of  the  disease,  in  a  vertical  direc- 
tion without  fear  of  constriction.  The  sutures  should  be  of  simple 
catgut,  and  the  ends  of  each  should  be  left  long  to  serve  as  tractors 
to  facilitate  the  introduction  of  the  succeeding  sutures;  when  the 
operation  is  complete  they  are  all  cut  short.  The  stitches  should  be 
interrupted;  every  second  stitch  should  pass  through  the  whole 
thickness  of  the  rectal  wall  and  the  intermediate  ones  through  the 
mucous  membrane  and  submucous  layers  only. 

If  an  accessory  posterior  incision  has  been  made  through  the 
wall  of  the  rectum  back  to  the  coccyx  this  part  of  the  wall  of  the 
rectum  should  also  be  closed  in  a  similar  manner,  but  the  back  part 
of  this  posterior  incision  which  opens  through  the  skin  behind  the 
anus,  between  it  and  the  coccyx,  should  be  left  partly  open  for  the 
purpose  of  drainage.  The  drainage  is  arranged  by  inserting  a  strip 
of  gauze,  which  is  packed  into  the  wound  behind  the  rectum  and  well 
up  as  far  as  the  site  of  the  suture  line.  This  packing  should  not  be 
tight,  but  should  surely  reach  to  the  bottom  of  the  wound. 

Volkmann  strongly  advises  drainage  in  all  cases  of  excision  of  a 
portion  of  the  wall  of  the  rectum  even  where  the  wall  of  the  rectum 
has  not  been  split  by  the  posterior  incision.  In  those  cases  where  the 
posterior  incision  through  the  rectal  wall  has  been  made  one  may 
drain  as  described  above.  If  the  posterior  incision  has  not  been 
made,  one  may  make  an  incision  in  the  skin  near  the  margin  of  the 
anus,  and  through  this  penetrate  sufficiently  deep  to  reach  the  site 
of  the  suture  line  in  the  wall  of  the  rectum  when  a  strip  of  gauze  is 
introduced. 

Innocent  Kectal  Polypi. — After  the  anus  has  been  dilated  these 
may  be  seized  with  a  clamp  and  twisted  off  the  wall  of  the  rectum 
with  great  ease  or  they  may  be  amputated  with  the  cautery.  They 
usually  do  not  bleed,  but,  if  they  do,  the  stump  may  be  clamped  and 
tied. 

Extirpation  of  the  Rectum,  Amputatio  Recti  (Volkmann). — 
Special  pains  should  be  taken  to  thoroughly  empty  the  bowel,  espe- 
cially above  the  point  of  constriction,  with  a  course  of  laxatives  and 
copious  rectal  irrigations.  This  preparatory  treatment  may  require 
several  days  or  a  week. 


408  RECTUM. 

This  operation  is  adapted  to  those  cases  in  which  the  disease 
has  already  involved  the  lower  part  of  the  rectum,  including  the 
anus — where  the  lower  end  of  the  bowel  (sphincter)  cannot  be  saved. 
The  diseased  portion,  including  the  anal  part,  is  amputated,  and 
after  this  has  been  accomplished  the  upper  part  of  the  gut  is  pulled 
down  and  sutured  to  the  margin  of  the  skin  about  the  anus. 

The  patient  is  placed  in  the  lithotomy  position.  A  strip  of  gauze 
may  first  be  introduced  into  the  rectum  to  prevent  leakage,  etc.,  and 
then  an  incision  which  encircles  the  anus  is  made  through  the  skin. 
This  incision  is  carried  down  into  the  loose  connective  tissue  about 
the  lower  end  of  the  rectum,  and,  when  this  part  of  the  bowel  has 
been  liberated  all  around,  it  is  seized  and  drawn  down.  The  levatores 
ani,  which  are  inserted  into  the  sides  of  the  lower  part  of  the  rectum, 
are  encountered.  These  are  divided  with  the  knife  or  scissors  close 
to  the  wall  of  the  rectum,  and  then,  gradually  working  deeper  and 
deeper,  the  rectum  is  thoroughly  separated  all  around  from  the  loose 
connective  tissue  which  surrounds  it,  and  pulled  down  more  and  more 
as  this  step  of  the  operation  progresses.  The  isolation  of  the  rectum 
is  accomplished  chiefly  by  dissecting  with  the  fingers  or  with  blunt- 
pointed  scissors. 

If  more  space  is  required,  accessory  incisions  may  be  added.  A 
posterior  incision  which  reaches  from  the  circular  incision  that  sur- 
rounds the  anus  backward  to  the  tip  of  the  coccyx  may  be  made. 
This  incision  may  still  farther  be  extended  upward  upon  the  back 
of  the  coccyx,  and,  if  necessary,  this  bone  may  be  enucleated,  after 
the  soft  parts  which  cover  it  have  been  separated  with  a  periosteum 
elevator.  An  anterior  incision  may  also  be  added;  this  passes  for- 
ward from  the  circular  incision  which  surrounds  the  anus  as  far  as 
the  bulb  of  the  urethra  in  the  male  and  the  posterior  wall  of  the 
vagina  in  the  female.  This  anterior  incision  not  only  provides  more 
room,  but  allows  the  operator  to  keep  himself  informed  of  the  loca- 
tion of  the  urethra  and  vagina,  and  may  thus  diminish  the  liability 
of  injuring  these  parts.  A  catheter  may  be  introduced  into  the 
bladder  as  an  additional  caution.  These  accessory  incisions  should 
not  extend  through  the  wall  of  the  rectum,  as  it  is  advisable  to  am- 
putate the  rectal  tube  intact,  without  cutting  into  it,  in  order  to 
avoid  soiling  the  wound  with  its  contents. 

In  liberating  the  rectum  in  the  female  we  have  to  separate  it 
upon  its  anterior  aspect  from  the  posterior  wall  of  the  vagina.  The 
vagina  may  also  be  involved  in  the  disease,  and  it  will  then  be  nee- 


OPERATIONS  UPON  THE  RECTUM.  409 

essary  to  excise  a  part  of  its  wall  together  with  the  rectum.  In  this 
case  one  should  pause  and  close  the  opening  made  in  the  vaginal 
wall  before  proceeding  further  with  the  isolation  of  the  rectum.  In 
the  male  the  rectum  has  to  be  separated  anteriorly  from  the  pros- 
tate and  from  the  base  of  the  bladder. 

As  we  continue  deeper  with  the  isolation  of  the  rectum  upon  its 
anterior  aspect,  especially  if  the  disease  reaches  pretty  well  up,  we 
meet  the  fold  of  peritoneum  which  dips  down  in  front  of  the  rectum: 
in  the  female  between  the  rectum  and  the  vagina,  in  the  male  be- 
tween the  rectum  and  the  bladder.  The  depth  to  which  this  peri- 
toneal fold  is  reflected  upon  the  front  wall  of  the  rectum  varies. 
Usually  it  descends  to  a  level  which  is  just  above  a  point  that  can 
be  reached  by  the  finger  introduced  into  the  rectum  through  the 
anus;  i.e.,  to  a  point  5  to  6  cm.  above  the  anus.  This  fold  may, 
however,  extend  down  to  a  point  within  a  short  distance  of  the  anus. 
If  this  fold  of  peritoneum  is  not  involved  in  the  disease,  it  may  be 
simply  stripped  away  from  the  front  wall  of  the  rectum  without 
opening  into  it.  At  times,  however,  it  is  opened,  either  intentionally 
when  it  is  diseased  or  accidentally.  This  is  of  no  special  significance, 
especially  if  the  rectum  itself  has  not  been  opened.  The  opening  in 
the  peritoneum  may  be  closed  at  once.  If  small,  its  edges  may  be 
caught  in  an  artery  clamp  and  tied  with  a  catgut  ligature  as  one 
ties  a  bleeding  vessel.  If  larger,  its  edge  may  be  sewed  to  the  peri- 
toneum that  covers  the  front  wall  of  the  rectum  with  several  catgut 
stitches,  or  it  may  be  left  unsutured  and  packed  with  gauze.  In 
separating  the  rectum  posteriorly  there  may  be  considerable  hemor- 
rhage. All  bleeding  vessels  should  be  clamped  as  they  are  cut.  Dis- 
eased glands  which  lie  behind  the  rectum  may  also  be  enucleated. 

After  having  separated  the  rectum  beyond  the  upper  limits  of 
the  disease  the  whole  tube  is  pulled  down  and  steadied  with  the 
vulsella  forceps,  which  serve  as  tractors,  grasping  the  bowel  above 
the  level  of  the  disease,  and  then  the  lower  diseased  portion  is  am- 
putated, making  a  straight  cut  transversely  across  the  bowel.  After 
this  has  been  done  the  edge  of  the  bowel  is  sewed  to  the  edges  of 
the  skin  around  the  anus  with  alternating  superficial  and  deep 
stitches  of  silk.  Before  the  edge  of  the  bowel  is  sewed  to  the  margins 
of  the  skin  about  the  anus  it  may  be  twisted  on  its  long  axis  through 
a  quarter  of  a  circle.  This  may  make  the  artificial  anus  somewhat 
more  retentive  (Gersuny).  If  twisted  to  a  greater  degree,  it  may  re- 
sult in  gangrene  of  the  lower  part  of  the  bowel. 


410  RECTUM. 

If  there  have  been  made  accessory  posterior  and  anterior  in- 
cisions, these  ma}-  be  closed  with  several  interrupted  sutures;  but 
this  closure  should  not  be  complete,  as  there  should  be  sufficient 
space  between  the  sutures  to  allow  free  drainage  from  the  parts  about 
the  rectum. 

Drainage  is  made  with  strips  of  gauze,  which  are  packed  loosely 
into  the  incision,  both  in  front  and  behind  the  rectum. 

Resection  of  the  Rectum  in  Continuity  (Dieff enbach) . — This  op- 
eration may  be  performed  for  excision  of  cicatricial  stricture  (Hal- 
sted). 

This  operation  is  applicable  to  those  cases  where  the  disease 
involves  the  wall  of  the  rectum  above  the  sphincter,  the  lower  portion 
of  the  tube  being  free  and  healthy. 

The  diseased  portion  of  the  rectum  is  resected  in  its  continuity 
and  the  lower  end  of  the  upper  healthy  segment  then  sutured  to  the 
upper  end  of  the  lower  healthy  anal  part,  which  includes  the  sphinc- 
ter. The  Kraske  method  of  resecting  the  rectum  is  probably  prefer- 
able to  this  method,  especially  if  the  parts  outside  the  rectum  are 
involved. 

After  the  sphincter  has  been  thoroughly  dilated  the  lower, 
healthy  part  of  the  rectum  is  divided  into  two  lateral  halves  by  two 
incisions,  one  of  wThich,  commencing  within  the  rectum,  passes  back- 
ward, dividing  the  lower  part  of  the  rectum,  including  the  anus,  back 
to  the  coccyx.  The  second  incision  divides  the  front  wall  of  the 
rectum,  passing  forward  through  the  perineum  as  far  as  the  bulb  of 
the  urethra  in  the  male  and  the  posterior  wall  of  the  vagina  in  the 
female.  Both  these  incisions  reach  upward  through  the  wall  of  the 
rectum  to  a  point  just  below  the  lower  limits  of  the  disease.  Two 
broad,  blunt-pronged  retractors  are  then  introduced,  one  on  either 
side,  and  the  wound  thus  held  wide  open. 

In  either  lateral  half  of  the  rectum  which  has  been  thus  split 
and  just  below  the  lower  limits  of  the  disease  a  transverse  incision 
is  now  made.  This  incision  passes  through  the  entire  thickness  of 
the  rectal  wall,  and  separates  the  lower  healthy  part  of  the  reetum 
from  the  upper  diseased  portion.  Into  these  lateral  incisions  upon 
either  side  of  the  rectum  the  blunt-pronged  retractors  are  intro- 
duced, and,  after  inserting  a  strip  of  gauze  into  the  diseased  portion 
to  prevent  its  contents  from  soiling  the  wound,  the  lower  cut  edge  of 
the  upper  diseased  portion  of  the  rectum  is  secured  with  vulsella 
forceps  or  silk  tractor  sutures,  wrhich  at  the  same  time  close  its  lower 


OPERATIONS  UPON  THE  RECTUM.  41 1 

end,  and  its  isolation  from  the  loose  connective  tissue  by  which  it  is 
surrounded  upon  all  sides  is  commenced.  Steadily  drawing  the  dis- 
eased portion  of  the  bowel  more  and  more  downward,  its  separation 
from  the  adjoining  connective  tissue  is  continued  until  it  is  entirely 
free  and  we  are  able  to  reach  beyond  the  upper  limits  of  the  disease. 
This  separation  of  the  rectum  is  accomplished  chiefly  by  blunt  dis- 
section with  the  finger  or  the  end  of  the  blunt-pointed  scissors,  work- 
ing all  the  time  fairly  close  to  the  rectal  wall.  Vessels  are  clamped 
as  they  are  cut  during  the  course  of  the  operation.  All  spurting 
vessels  should  be  ligated. 

In  liberating  the  rectum  anteriorly  we  may  meet  the  fold  of 
peritoneum  that  projects  downward  upon  its  front  aspect.  If  this 
is  not  involved  in  the  disease  it  can  usually  be  peeled  away  from  the 
wall  of  the  rectum  with  the  finger  without  opening  into  it.  If  dis- 
eased, or  if  it  cannot  be  separated  from  the  front  wall  of  the  rectum, 
we  may  cut  through  it  close  to  the  wall  of  the  rectum,  and,  intro- 
ducing the  finger  into  the  opening  thus  made,  draw  the  rectum  down. 
A  pad  may  be  temporarily  introduced  to  prevent  the  prolapse  of  in- 
testine through  the  opening  and  to  protect  the  peritoneal  cavity. 
After  the  rectum  has  been  drawn  down  for  a  sufficient  distance  the 
opening  in  the  peritoneum  may  be  closed  by  suturing  its  edge  with 
catgut  to  the  peritoneal  layer  {hat  covers  the  anterior  wall  of  the 
rectum,  or  it  may  be  left  unsutured  and  drained  with  a  strip  of  gauze, 
which  is  left  protruding  through  the  wound  in  the  perineum  in  front 
of  the  anus.  The  part  of  the  rectum  above  the  disease  should  not 
be  separated  from  its  surrounding  parts  any  more  than  is  absolutely 
necessary  to  permit  its  being  drawn  down  to  the  edge  of  the  lower 
segment  of  the  bowel,  and  furthermore  one  should  not  work  too  close 
to  the  wall  of  the  rectum  in  order  not  to  damage  the  blood-supply  to 
such  a  degree  that  the  nutrition  of  the  rectum  might  be  seriously 
impaired. 

After  the  rectum  has  been  liberated  to  a  point  beyond  the  upper 
limits  of  the  disease  we  may  then  proceed  to  excise  the  diseased  por- 
tion. Before  doing  this  two  tractors  of  silk  are  passed  through  the 
whole  thickness  of  the  wall  of  the  rectum  above  the  diseased  area  in 
order  to  steady  it  and  to  hold  it  after  the  diseased  segment  has  been 
excised.  When  this  has  been  accomplished  the  end  of  the  healthy 
bowel  is  drawn  down  and  sutured  to  the  upper  edge  of  the  lower  seg- 
ment (anal  portion).  This  is  done  with  fine  silk  sutures  which 
alternately  pass  through   the   whole   thickness   of  the   bowel   and 


412  RECTUM. 

through  the  mucous  membrane  only.  The  edges  of  the  anterior  and 
posterior  incisions  in  the  lower  segment  of  the  rectum,  including  the 
ends  of  the  sphincter,  are  then  brought  together  in  a  similar  manner, 
and  thus  the  continuity  of  the  bowel  is  restored.  The  incision  in  the 
skin  in  front  of  the  anus  and  that  behind  the  anus  are  only  partly 
closed,  and  a  strip  of  gauze  is  packed  to  the  bottom  of  each  incision, 
as  thorough  drainage  is  imperative.  Before  commencing  the  suture 
of  the  bowel  the  parts  may  be  irrigated  and  a  soft  rubber  tube  sur- 
rounded by  gauze  introduced  well  up  into  the  upper  part  of  the 
rectum  beyond  the  proposed  site  of  suture.  This  is  to  prevent  soil- 
ing of  the  suture  line,  and  also  to  allow  the  passage  of  gas  and  pos- 
sibly fluid  faeces  during  the  few  days  immediately  following  the 
operation. 

If  the  peritoneal  pouch  has  been  opened  and  packed  the  end 
of  the  gauze  packing  emerges  through  the  incision  in  the  perineum 
in  front  of  the  anus. 

Resection  and  Amputation  of  Rectum  through  the  Sacral  Route 
(Kraske). — This  method  is  well  adapted  for  resectio  recti  for  disease 
situated  high  up,  but  with  the  lower  end  of  the  rectum  and  the  anus 
still  healthy.  It  also  furnishes  the  best  route  for  amputatio  recti  in 
those  cases  where  the  anal  portion  is  also  involved. 

The  bowel  should  be  thoroughly  emptied  before  the  operation 
by  a  course  of  laxatives  and  repeated  rectal  irrigations.  This  prepar- 
atory treatment  should  be  thorough,  and  may  require  one  or  two 
weeks.  If  the  stricture  of  the  rectum  is  so  tight  that  the  bowel 
above  the  site  of  the  constriction  cannot  be  emptied  before  the 
operation,  one  may  do  a  preliminary  colostomy.  This  should  be  done 
one  or  two  weeks  before  the  rectal  operation.  The  transverse  colon 
should  be  used  for  this  purpose,  because  if  the  sigmoid  or  the  de- 
scending colon  is  used  there  may  be  some  difficulty  in  drawing  down 
the  bowel  at  the  time  of  the  rectal  operation. 

For  Eesectio  Eecti  (the  anal  portion  being  healthy). 

The  operation  is  described  in  three  steps: — 

1.  Sacral  "Vor  operation":  resection  of  the  coccyx  and  part  of 
the  sacrum. 

2.  Eesection  of  the  diseased  portion  of  the  bowel. 

3.  Apposition  of  the  ends  of  the  bowel  and  treatment  of  the 
incision,  etc. 

Sacral  "Vor  Operation." — The  patient  lies  upon  the  left  side 
(Hochenegg),  with  the  belly  inclined  somewhat  toward  the  table,  the 


OPERATIONS  UPON  THE  RECTUM. 


413 


lower  limbs  strongly  flexed  at  the  knees  and  hips,  and  supported  thus 
by  an  assistant,  or  he  may  rest  upon  the  abdomen  with  the  lower 
limbs  hanging  over  the  end  of  the  table.  A  slightly  curved  incision 
with  the  concavity  toward  the  left  is  made.  It  begins  above  on  a 
level  with  the  middle  of  the  sacrum  and  from  two  to  three  fingers' 
breadth  (about  two  inches)  to  the  left  of  the  middle  line;  it  is  carried 
down  to  the  middle  of  the  upper  border  of  the  coccyx,  and  from  this 
point  it  is  continued  down  in  the  middle  line  upon  the  coccyx,  ending 
at  its  tip.  This  incision  divides  the  skin,  subcutaneous  fat,  and  super- 
ficial fascia,  and  exposes  in  the  upper  part  of  the  wound  the  lower  por- 
tion of  the  gluteus  maximus  muscle,  the  fibers  of  which  run  at  right 
angles  to  the  line  of  the  incision. 


!****^§ss§^ 


"■     ■""■■■■ 


Fig.  171; — Incision  for  Resection  of  the  Rectum  (Kraske). 


That  part  of  the  gluteus  maximus  muscle  which  presents  itself 
in  the  wound  is  incised  and  retracted,  and  there  are  then  exposed, 
lying  underneath,  the  attachment  to  the  sacrum  of  the  greater  and 
lesser  sacro-sciatic  ligaments.  These  structures  are  also  divided  close 
to  the  edge  of  the  sacrum. 

In  dividing  the  gluteus  maximus  muscle  branches  of  the  gluteal 
artery  are  cut;  these  may  be  clamped  and  tied.  Penetrating  through 
the  fat  in  the  ischio-rectal  fossa  the  coccygeus,  which  is  attached  to 
the  border  of  the  coccyx  and  sacrum,  and  the  levator  ani,  which  is 
attached  to  the  coccyx  near  its  tip,  are  exposed.  These  muscles  are 
covered  over  by  a  thin  fascia — the  anal;  they  are  divided  with  the 
knife  close  to  the  edge  of  the  sacrum  and  coccyx.    The  soft  parts  are 


414 


RECTUM. 


then  separated  with  a  periosteum  elevator  from  the  posterior  surface 
and  right  horder  of  the  coccyx,  and  while  it  is  forced  forward  the 
sacro-coccygeal  joint  is  opened  from  behind  and  the  hone  seized  with 
the  bone  forceps  and  extirpated.  The  sphincter  ani  is  cut  away  from 
the  tip  of  the  coccyx  close  to  the  bone.  If  the  arteria  sacra  media, 
which  descends  in  front  of  the  sacrum,  is  injured,  it  may  be  clamped 
and  tied. 

The  levator  ani  and  coccygeus  muscles  having  been  already  di- 
vided, the  operator  now  penetrates  through  the  loose,  fatty  tissue 
which  lies  behind  the  rectum  with  the  fingers  so  as  to  expose  the 
posterior  surface  of  the  rectum.  The  rectum  moves  with  respiration, 
and  shows  an  impulse  if  the  patient  coughs  or  strains. 


Fig.  172.— Back  Part  of  Ilium  and  Sacrum.  Coccyx  removed.  A,  A,  usual 
line  of  section  through  sacrum;  A,  B,  line  of  section  to  remove  all  of  lower 
part  of  sacrum;  SI,  lower  end  of  sacro-iliac  articulation;  1,  2,  3,  4,  poste- 
rior sacral  foramina. 


In  many  cases  one  may  proceed  at  once  with  the  second  step  of 
the  operation:  the  extirpation  of  the  diseased  part  of  the  rectum. 
At  times,  however,  the  space  is  not  sufficiently  ample,  especially  if 
the  tumor  is  adherent  and  cannot  be  readily  drawn  down  into  the 
wound,  or  if  the  space  between  the  border  of  the  sacrum  and  the 
ascending  ramus  of  the  ischium  (spatium  sacro-ischiadicum,  Kraske) 
is  unusually  narrow.  In  these  cases  in  order  to  obtain  more  room 
it  will  be  necessary  to  resect  a  portion  of  the  sacrum.  This  may  be 
done  with  the  chisel,  bone  forceps,  or  saw.  The  soft  parts  are  sepa- 
rated from  the  lower  part  of  the  left  half  of  the  posterior  surface  of 
the  sacrum  with  the  periosteum  elevator,  and  that  portion  of  the 


OPERATIONS   UPON   THE   RECTUM.  415 

sacrum  then  resected  which  lies  below  a  line  that  commences  at  the 
left  border  of  the  bone,  just  below  the  level  of  the  third  posterior 
sacral  foramen;  curving  downward  and  inward  toward  the  middle 
line  and  passing  between  the  third  and  fourth  posterior  sacral  fo- 
ramina, this  line  terminates  at  the  middle  of  the  lower  border  of  the 
sacrum.  If  necessary  to  get  still  more  room  the  line  of  section 
through  the  sacrum  may  be  carried  straight  across  the  sacrum,  just 
below  the  third  posterior  sacral  foramina  from  the  left  to  the  right 
border  of  the  bone,  thus  removing  all  of  the  sacrum  below  the  third 
sacral  foramina.  The  line  of  section  through  the  sacrum  may  ter- 
minate at  any  point  between  those  described  above.  The  guide  to 
the  location  of  the  third  sacral  foramen  is  the  lower  end  of  the  sacro- 
iliac articulation.  The  lower  end  of  the  sacro-iliac  articulation  lies 
just  above  the  lower  margin  of  the  third  posterior  sacral  foramen. 

In  making  the  resection  of  the  sacrum  it  is  unwise  to  go  above 
the  lower  border  of  the  third  posterior  sacral  foramen  on  account 
of  the  important  structures  which  emerge  from  the  first,  second,  and 
third  anterior  sacral  foramina  (sacral  plexus).  Through  the  fourth 
anterior  sacral  foramen  branches  emerge  which  are  distributed  to 
the  bladder  and  the  rectum.  If  these  branches  are  damaged  some 
disturbance  of  the  function  of  these  organs  will  follow,  but  this  is 
only  temporary,  control  being  rapidly  regained.  If  the  left  half  only 
of  the  lower  portion  of  the  sacrum  is  removed,  this  disturbance  will 
be  much  less  marked. 

Kesection  of  the  Diseased  Portion  of  the  Bowel  (the 
Anal  Portion  being  Free  from  Disease). — With  the  fingers  the 
diseased  portion  of  the  rectum  is  freed  upon  its  posterior  aspect 
and  upon  the  sides  from  the  loose  fat  and  connective  tissue  that  sur- 
round it.  It  is  then  likewise  freed  upon  its  anterior  aspect.  As  we 
proceed  with  the  isolation  of  the  rectum,  it  may  be  necessary  to  cut 
some  connective  tissue  bands  with  the  scissors.  All  blood-vessels 
are  clamped  and  tied  as  they  are  divided.  During  this  step  of  the 
operation  one  should  take  care  not  to  open  into  the  rectum.  "When 
the  diseased  part  of  the  rectum  has  been  thus  freed  all  around,  a 
heavy  silk  ligature  or  strip  of  gauze  is  tied  tightly  around  it,  just 
below  the  lower  limits  of  the  disease,  and  through  the  anus,  the  lower 
part  of  the  bowel,  after  being  again  thoroughly  irrigated,  is  packed 
with  gauze.  The  bowel  is  then  divided  transversely  below  the  liga- 
ture with  the  scissors  or  knife,  thus  cutting  the  diseased  portion  away 
from  the  lower  healthy  (anal)  segment  of  the  bowel.    The  wound  is 


416 


RECTUM. 


not  soiled,  because  the  diseased  segment  is  shut  off  by  the  ligature 
which  has  been  applied  about  it,  and  the  lower  anal  segment,  besides 
having  been  thoroughly  sterilized,  is  packed  with  gauze. 


Fig.  173.— Resection  of  Rectum  {Kraskc).  Rectum  exposed  and  ligature 
passed  around  it  just  below  the  diseased  portion  (*)  that  is  to  be  excised. 
A,  line  of  incision  through  rectum. 


Fig.  174.— Resection  of  Rectum  (Kraske).  Diseased  portion  (*)  cut  away 
from  the  healthy  lower  anal  portion.  \  ligature  has  been  placed  about  the 
rectum  just  above  the  diseased  portion.  B,  line  of  section  that  separates  the 
diseased  portion  from  the  healthy  upper  portion. 

The  diseased  portion  of  the  gut  is  now  seized,  and,  while  trac- 
tion is  made,  it  is  gradually  dissected  out  of  its  bed  of  fat  and  con- 
nective tissue,  being  thoroughly  isolated  upon  all  sides,  so  that  it 


OPERATIONS   UPON   THE   RECTUM.  417 

can  be  pulled  down  as  far  as  necessary.  This  is  accomplished  largely 
by  blunt  dissection  with  the  fingers.  Just  beyond  the  upper  limits 
of  the  disease,  when  this  becomes  feasible,  a  second  ligature  is  thrown 
around  the  rectum  and  tied,  and  thus  the  contents  of  the  diseased  seg- 
ment are  imprisoned  within  that  portion  of  the  bowel  which  is  to  be 
resected.  The  rectum  is  now  drawn  out  of  the  wound  as  far  as  possible, 
and  placed  upon  sterile,  gauze  pads,  and  the  diseased  part  cut  away 
from  the  upper  healthy  portion  of  the  bowel.  Before  this  is  done  an 
assistant  grasps  and  compresses  the  lower  part  of  the  upper  healthy 
segment  of  the  bowel,  beyond  the  intended  line  of  section,  between  the 
fingers,  so  that,  when  the  diseased  portion  is  cut  away,  the  end  of 
the  bowel  cannot  escape,  and  also  to  prevent  the  escape  of  its  con- 
tents. Should  there,  however,  accidentally  be  any  leakage,  the  wound 
is  protected  by  the  compress  which  has  been  arranged  beneath  the 
bowel  before  the  section  is  made. 

The  diseased  portion  having  been  thus  excised,  the  proximal,  or 
upper,  segment  of  the  bowel  is  immediately  packed  with  gauze. 
Bleeding  from  the  edge  of  the  bowel  may  be  checked  by  clamps  and, 
if  necessary,  ligatures. 

In  freeing  the  rectum  upon  its  anterior  aspect,  one  has  to  deal 
with  the  pouch  of  peritoneum  which  dips  down  upon  its  front  wall, 
between  it  and  the  uterus  and  vagina  in  the  female  and  the  bladder 
in  the  male.  One  should  recognize  this  pouch,  as  it  may  be  necessary 
to  open  it,  and,  indeed,  this  is  probably  desirable  in  all  cases,  as  it 
enables  one  to  bring  down  the  upper  part  of  the  bowel  with  more 
ease.  After  an  opening  has  been  made  into  this  pouch,  it  may  be 
enlarged  by  cutting  with  the  scissors,  upon  either  side,  close  to  the 
wall  of  the  rectum;  through  the  opening  thus  made  two  fingers  may 
be  introduced  and  the  bowel  drawn  down;  after  it  has  been  pulled 
down  sufficiently,  one  may  sew  the  edge  of  the  opening  in  the  peri- 
toneum to  the  peritoneal  layer  that  covers  the  bowel,  upon  either 
side,  with  several  catgut  sutures;  the  anterior  portion,  however, 
should  be  left  open  for  drainage.  Kraske  advises  against  closing  this 
opening  in  the  peritoneal  pouch  even  in  part.  He  says  that  it  should 
be  loosely  packed  with  strip  gauze,  surrounding  the  rectum  in  front, 
upon  the  sides,  and  behind,  and  reaching  well  up  into  the  peritoneal 
cavity;  the  extremities  of  the  gauze  strips  are  allowed  to  emerge 
through  the  upper  part  of  the  skin  incision,  and  should  be  marked 
for  identification,  so  that  they  may  be  removed  after  five  or  six  days. 
If  this  fold  of  peritoneum  is  involved  in  the  disease,  it  may  be  oblit- 


418  RECTUM. 

erated  by  its  opposing  surfaces  having  become  agglutinated,  or  the 
growth  may  have  extended  still  farther  so  as  to  involve  the  uterus  or 
bladder.  This  will  add  to  the  difficulty  of  the  operation;  but  some 
surgeons  do  not  consider  it  a  counter-indication  to  the  continuance 
of  the  operation,  because,  if  necessary,  the  parts  of  these  organs  that 
are  involved  may  be  resected. 

If  the  peritoneal  fold  is  not  involved  in  the  disease  it  can  usually 
be  peeled  away  from  the  front  wall  of  the  rectum  with  the  finger, 
and  in  this  case  one  may  be  able  to  complete  the  operation  without 
opening  into  the  peritoneal  cavity. 

Diseased  lymphatic  nodes  located  behind  the  rectum,  between 
it  and  the  sacrum,  should  also  be  enucleated.  There  may  be  con- 
siderable bleeding  caused  by  separating  the  rectum  upon  its  posterior 
aspect  and  sides  from  branches  of  the  superior  hemorrhoidal;  they 
should  be  clamped  and  ligated. 

Suture  of  the  Ends  of  the  Bowel. — The  upper  segment 
should  be  sutured  to  the  lower  (anal  portion),  and  this  union  may  be 
either  complete  or  partial. 

Complete  Union,  the  Ideal  Method. — During  the  application  of 
the  sutures  care  should  be  taken  that  no  fasces  soil  the  suture  line; 
a  wad  of  gauze  packed  into  the  upper,  central,  segment  of  the  bowel 
prevents  this.  There  should  be  no  tension  on  the  upper  segment — 
no  tendency  for  it  to  draw  up  into  the  abdomen  away  from  the  anal 
portion.  Proper  isolation  of  the  rectum  and  the  opening  of  the  peri- 
toneal pouch  will  obviate  this. 

One  may  further  fix  the  upper,  central,  segment  of  the  bowel  in 
the  wound  by  several  non-perforating  sutures.  For  uniting  the  ends 
of  the  bowel  fine  silk  sutures  should  be  used.  One  may  commence 
the  suture  in  the  middle  line  anteriorly  and  work  around  upon  either 
side  toward  the  back.  The  sutures  should  be  introduced  from  the 
inner  surface  of  the  bowel  and  tied  so  that  the  knots  are  within  the 
lumen  of  the  bowel — they  should  be  interrupted,  and  each  should 
include  the  whole  thickness  of  the  wall  of  the  gut,  and  be  placed 
about  1/2  cm.  distant  from  each  other.  Those  sutures  which  are 
introduced  last,  and  which  join  the  two  segments  of  the  bowel  poste- 
riorly, must  be  introduced  from  the  outer  surface,  and  do  not  pene- 
trate the  whole  thickness  of  the  wall  of  the  bowel,  but  simply  include 
the  outer  coats.  When  these  latter  sutures  are  tied,  the  knots  will 
be  found  upon  the  outer  aspect  of  the  bowel.  Before  closing  this 
posterior  portion  of  the  wound  Hochenegg  advises  the  introduction 


OPERATIONS   UPON   THE   RECTUM.  419 

of  a  rubber  tube  surrounded  by  gauze  from  the  anus  well  up  into 
the  bowel  beyond  the  suture  line.  This  prevents  soiling  of  the  suture 
line  and  also  permits  the  passage  of  gas  and  fluid  fseces  during  the 
few  days  immediately  following  the  operation.  A  strip  of  gauze 
should  be  introduced  into  the  wound,  so  as  to  lead  from  the  suture 
line  upon  each  side  of  the  bowel  out  through  the  incision,  for  the 
purpose  of  providing  drainage  for  this  part,  in  the  event  of  the 
sutures  giving  way.  There  is  some  danger  in  complete  closure  of 
the  bowel.  The  sutures  may  tear  through  and  allow  the  contents 
of  the  bowel  to  escape  into  the  wound,  especially  if  the  obstruction 


Fig.  175.— Resection  of  Rectum  (Kraslce).  Diseased  portion  has  been  ex- 
cised and  the  healthy  upper  and  lower  portions  have  been  partially  united 
with  interrupted  sutures  that  penetrate  the  entire  thickness  of  the  wall  of 
the  bowel. 

offered  by  the  disease  had  prevented  the  complete  evacuation  of  the 
bowel  before  the  operation.  Masses  of  fasces  come  down  and  put  a 
strain  upon  the  stitches;  if  this  accident  occurs,  the  wound  becomes 
infected,  and  we  may  get,  as  a  result,  a  fatal  peritonitis. 

Union  most  often  fails  in  the  posterior  part  of  the  suture  line 
in  the  bowel;  this  is  due  probably  to  the  damage  done  to  the  vessels 
which  supply  the  bowel,  in  isolating  it.  Such  a  break  of  the  suture 
line,  however,  usually  does  no  harm  if  proper  drainage  of  the  wound 
has  been  provided,  and  usually  the  resulting  faecal  fistula  closes  spon- 
taneously, or  may  be  closed  by  use  of  adhesive  plaster  strips  in  dress- 
ing or  by  a  subsequent  operation. 


420  RECTUM. 

Partial  Union. — Instead  of  making  a  complete  union  we  may 
join  the  ends  of  the  segment  of  the  bowel  only  anteriorly  and  upon 
the  sides,  leaving  the  posterior  part  of  the  wound  open.  The  upper 
segment  of  the  bowel  is  then  fixed  in  the  wound  to  prevent  its  re- 
traction. In  this  case  we  wait  for  the  faecal  fistula  that  results  to 
close  spontaneously,  or  else  we  accomplish  this  by  a  subsequent 
operation. 

However  the  ends  of  the  bowel  are  treated,  the  wound  should 
be  well  packed  with  iodoform  gauze — not  too  tight,  but  reaching 
well  down  to  the  bottom  of  all  parts  of  the  wound.  This  packing  is 
allowed  to  remain  until  it  becomes  loosened, — usually  for  about  one 
week, — when  the  wound  is  again  dressed  and  repacked.  The  incision 
in  the  skin  is  partly  closed. 

For  Amputatio  Eecti  (the  Anal  Portion  or  the  Bowel  being 
Involved  in  the  Disease). — If  it  is  desired  to  remove  the  lower 
(anal)  portion  of  the  bowel,  together  with  the  rest  of  the  rectum,  the 
skin  incision  should  be  prolonged  from  the  tip  of  the  coccyx,  so  as  to 
encircle  the  anus.  After  the  coccyx  and  part  of  the  sacrum  have  been 
resected  as  described  above,  the  whole  length  of  the  bowel,  including 
the  anal  portion,  is  isolated,  beginning  below  at  the  anus  and  work- 
ing upward.  Upon  either  side  near  the  anus  the  attachment  of  the 
levator  ani  is  separated  from  the  rectum  with  the  scissors,  working 
close  to  the  wall  of  the  rectum.  At  times,  some  difficulty  in  sepa- 
rating the  rectum  from  the  prostate  or  the  vagina  is  experienced. 
A  sound  may  be  introduced  into  the  bladder,  and  this  part  of  the 
operation  done  in  the  perineal  position.  This  change  of  position, 
however,  is  probably  unnecessary.  When  the  bowel  has  been  isolated 
to  a  point  beyond  the  upper  limits  of  the  disease,  a  ligature  may  be 
thrown  around  the  rectum  and  the  diseased  portion  cut  away.  The 
end  of  the  proximal  (upper)  part  of  the  bowel  into  which  a  strip  of 
gauze  has  been  packed  is  then  sewed  to  the  margins  of  the  skin  in 
the  upper  part  of  the  incision  close  to  the  edge  of  the  sacrum  with 
interrupted  silk  sutures.  The  wound  is  then  packed  carefully  about 
the  bowel,  above  and  below,  and  the  skin  incision  partly  closed  with 
several  silk  sutures.  The  bowel  may  be  twisted  through  a  quarter  of 
a  circle  before  uniting  it  to  the  margin  of  the  skin,  with  the  idea  of 
making  the  artificial  anus  more  retentive. 


PART  VII. 

HERNIA,  SPERMATIC  CORD,  TESTES,  ETC. 


The  Surgical  Anatomy  of  the  Groin. — The  groin  may  be  divided 
into  the  inguinal  and  femoral  regions.  These  parts  may  be  consid- 
ered more  or  less  together,  on  account  of  the  close  relationship  that 
exists  between  them. 

The  inguinal  region  corresponds  to  that  part  of  the  anterior 
abdominal  wall  which  lies  just  above  Poupart's  ligament,  and  is 
traversed  by  a  canal  for  the  passage  of  the  spermatic  cord,  in  the 
male,  and  the  round  ligament,  in  the  female.  By  invaginating  the 
integument  of  the  scrotum,  the  finger  may  be  introduced  into  this 
canal. 

The  femoral  region  corresponds  to  the  upper  anterior  part  of 
the  thigh — the  area  immediately  below  Poupart's  ligament.  Under- 
neath Poupart's  ligament,  between  it  and  the  pubic  bone,  there  is  a 
space  through  which  the  ilio-psoas  muscle  and  anterior  crural  nerve, 
and  the  femoral  vessels,  etc.,  pass  from  the  abdomen  into  the  thigh. 

The  Superficial  Layer  of  the  Superficial  Fascia.  —  Be- 
neath the  skin  of  the  groin  there  is  a  loose  connective  tissue  layer 
which  contains  a  varying  amount  of  fat,  and  in  which  the  blood- 
vessels, nerves,  lymphatic  glands,  etc.,  are  located.  This  layer  is 
called  the  superficial  layer  of  the  superficial  fascia.  In  some  subjects 
it  is  very  thick.  It  is  continuous  with  the  general  fatty  layer  of  the 
body.  In  the  male  it  is  continued  on  to  the  penis,  where  it  is  thin 
and  loose,  forming  one  of  the  coats  of  that  organ,  and  in  the  scrotum 
is  continued  into  the  dartos.  From  the  scrotum  it  may  be  traced 
back  into  the  perineum,  where  it  is  known  as  the  superficial  layer 
of  the  superficial  perineal  fascia.  In  the  female  it  is  continuous  with 
the  fatty  layer  of  the  labia  majora,  each  one  of  which  corresponds 
to  one-half  of  the  scrotum.  The  vessels  which  are  found  in  this 
layer,  and  which  may  be  cut  in  making  the  skin  incisions  in  operating 
upon  these  parts,  are  the  superficial  epigastric,  superficial  circumflex 
iliac,  and  superficial  external  pudic  arteries,  together  with  their  cor- 
responding veins. 

(421) 


422  HERNIA,  ETC. 

The  Lymphatic  Glands. — The  lymphatic  glands  of  this  region 
are  arranged  in  two  groups:  one  group,  the  inguinal,  is  spread  along 
Poupart's  ligament,  and  drains  the  external  genitals,  scrotum,  penis, 
etc.;  the  other  group  lies  along  the  saphenous  vein,  and  in  and  about 
the  saphenous  opening.  These  drain  the  lower  limb.  In  extirpating 
the  inguinal  group  of  glands  there  is  but  little  hemorrhage,  but  it 
is  necessary  to  avoid  the  spermatic  cord.  In  extirpating  the  lower, 
femoral,  group  there  may  be  considerable  hemorrhage,  and  one  must 
avoid  injury  to  the  internal  saphenous  vein  and  to  the  femoral  vein, 
especially  when  excising  those  glands  that  are  lodged  in  the  saphe- 
nous opening. 

The  Deep  Later  of  the  Superficial  Fascia. — After  the  fatty 
layer  has  been  removed  from  this  region  the  deep  layer  of  the  super- 
ficial fascia  is  exposed.  This  fascia  is  thin,  and  covers  the  aponeu- 
rosis of  the  external  oblique  muscle  in  the  inguinal  region,  and  the 
fascia  lata  in  the  femoral  region.  It  is  adherent,  in  the  middle  line, 
to  the  linea  alba,  and,  just  below  Poupart's  ligament,  to  the  fascia 
lata.  In  the  male  it  forms  one  of  the  coverings  of  the  penis,  and  is 
continued  into  the  scrotum,  where  it  forms  the  dartos,  and  backward 
beyond  the  scrotum,  into  the  perineum,  where  it  forms  the  deep  layer 
of  the  superficial  perineal  fascia.  In  the  perineum  it  is  attached 
laterally  to  the  rami  of  the  pubes,  and  behind  to  the  transverse  peri- 
neal raphe.  In  the  female  this  layer  is  continued  into  the  labia 
majora.  This  fascia  is  firmly  attached  to  the  margins,  or  pillars,  of 
the  external  ring,  and  is  known  as  the  external  spermatic  fascia. 
Entrance  into  the  inguinal  canal  cannot  be  effected  until  this  layer 
of  fascia  has  been  incised.  From  the  margins  of  the  ring  this  layer 
of  fascia  is  continued  downward,  surrounding  the  cord  and  forming 
one  of  its  investments,  and  below,  as  already  mentioned,  it  is  found 
in  the  scrotum  as  the  dartos.  Below  Poupart's  ligament,  in  the 
femoral  region,  this  layer  of  fascia  is  firmly  adherent  to  the  margins 
of  the  saphenous  opening  in  the  fascia  lata,  where  it  is  perforated 
by  numerous  vessels  and  lymphatics,  and  is  called  the  cribriform 
fascia.  From  this  point  on,  the  inguinal  and  femoral  regions  may  be 
studied  separately. 

The  Inguinal  Eegion.- — The  inguinal  region  is  the  site  of  in- 
guinal hernia.  After  removing  the  deep  layer  of  the  superficial 
fascia  from  the  inguinal  region  (including  the  margins  of  the  exter- 
nal ring),  we  expose  the  aponeurosis  of  the  external  oblique  and  the 
external  inguinal  ring,  into  which  the  finger  may  be  introduced,  and 


Fig.  176.— Inguinal  and  Femoral  Regions.  FP,  edge  of  falciform  process:  FT.  femoral 
vein;  LA,  linea  alba;  LIS,  linea  semilunaris;  P,  Poupart's  ligament.  The  external 
inguinal  ring  is  shown  with  the  spermatic  cord  emerging.  The  fibers  crossing  the  upper 
outer  angle  of  the  ring  are  known  as  the  intercolumnar  fibers. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  423 

from  which  the  spermatic  cord  (the  round  ligament  in  the  female) 
is  seen  to  emerge. 

The  aponeurosis  of  the  external  oblique  is  the  strong,  smooth, 
glistening,  bluish-white,  fibrous  expansion  of  the  external  oblique 
muscle.  Its  fibers  have  an  oblique  direction  downward  and  inward 
toward  the  middle  line,  and  join  with  each  other  in  the  linea  alba. 
The  lower  fibers  of  the  aponeurosis  of  the  external  oblique  are  col- 
lected into  a  thick  bundle  to  form  Poupart's  ligament. 

Poupart's  ligament  is  a  strong,  fibrous  band  which  extends  from 
the  anterior  superior  spinous  process  of  the  ilium  downward  and 
inward  to  the  spine  of  the  pubes.  Both  these  bony  processes  are 
easily  made  out;  the  latter,  the  spine  of  the  pubes,  is  readily  felt 
beneath  the  soft  parts  upon  the  upper  border  of  the  pubic  bone, 
about  three-fourths  inch  from  the  symphysis.  The  fibers  of  the 
aponeurosis  of  the  external  oblique  immediately  above  Poupart's 
ligament  pass  inward  toward  the  middle  line,  interlacing  with  those 
from  the  opposite  side,  and  are  attached  to  the  symphysis,  and  there 
is  thus  left  a  triangular  opening  in  the  aponeurosis,  which  is  called 
the  external  inguinal  ring.  This  so-called  ring  is  simply  a  split  in 
the  aponeurosis  of  the  external  oblique.  Its  outer,  or  lower,  border, 
or  pillar,  is  formed  by  Poupart's  ligament;  its  inner,  or  upper, 
border,  or  pillar,  is  formed  by  those  fibers  of  the  aponeurosis  of  the 
external  oblique  which  are  attached  in  the  middle  line  to  the  sym- 
physis, interlacing  with  those  of  the  opposite  side.  The  apex  of  this 
opening  is  directed  upward  and  outward;  its  base  corresponds  to  the 
crest,  or  upper  surface,  of  the  body  of  the  pubic  bone,  that  portion 
of  the  bone  which  is  included  between  the  pubic  spine,  to  which  Pou- 
part's ligament  is  attached,  and  the  symphysis.  Various  stay  fibers 
are  seen  in  the  aponeurosis,  passing  from  below  upward  and  inward, 
near  the  apex  of  the  external  ring.  These  serve  to  bind  the  pillars 
of  the  ring  firmly  together,  and  are  called  the  intercolumnar  fibers. 

The  spermatic  cord  (round  ligament  in  the  female)  is  seen 
emerging  from  the  external  ring,  and  a  director  may  be  introduced 
through  the  ring  upward  and  outward  into  the  inguinal  canal.  From 
the  inner  end  of  Poupart's  ligament — i.e.,  from  the  external  pillar 
of  the  ring — a  triangular  sheet  of  fibers  is  given  off,  which  is  reflected 
upward  and  inward  toward  the  middle  line,  and  is  continued  into  the 
anterior  layer  of  the  sheath  of  the  rectus  muscle.  This  is  called  the 
triangular  ligament,  or  Colles's  ligament,  and  is  situated  behind  the 
inner  end  of  the  external  ring,  and  in  front  of  the  conjoined  tendon, 


424  HERNIA,  ETC. 

and  serves  to  strengthen  this  part.  If  we  examine  still  further  this 
inner  end  of  Poupart's  ligament, — i.e.,  the  external  pillar  of  the 
ring, — we  find  given  off  from  its  lower  border,  just  before  its  attach- 
ment to  the  pubic  spine,  a  strong  triangular  band,  which  is  attached 
to  the  ilio-pectineal  line,  a  prominent  ridge  upon  the  upper  surface 
of  the  pubic  bone,  which  is  continued  outward  and  backward  from 
the  pubic  spine  to  the  edge,  or  brim,  of  the  true  pelvis.  This  band 
in  known  as  Gimbernafs  ligament.  It  presents  an  outer,  sharp, 
curved  edge,  and  is  of  much  anatomical  interest  in  the  study  of 
femoral  hernia. 

The  Inguinal  Canal. — The  inguinal  canal  is  an  oblique  slit  in 
the  abdominal  wall,  and,  under  ordinary  circumstances,  the  greater 
the  intra-abdoniinal  pressure,  the  tighter  its  closure.  It  is  from  4 
to  5  cm.  (one  and  one-half  inches)  long,  and  lies  above  and  parallel 
with  Poupart's  ligament.  It  terminates  beneath  the  integument  at 
the  external  inguinal  ring,  a  triangular  opening  in  the  aponeurosis  of 
the  external  oblique,  which  is  located  just  above  the  crest  of  the 
pubes. 

If  we  introduce  a  director  through  the  external  ring  into  the 
inguinal  canal,  and  pass  it  in  a  direction  upward  and  outward  under- 
neath the  aponeurosis  of  the  external  oblique,  to  a  point  about  half 
an  inch  above  the  middle  of  Poupart's  ligament, — i.e.,  the  location  of 
the  internal  ring, — and  then  split  the  aponeurosis  upon  this,  we 
open  up  the  inguinal  canal  and  expose  its  contents:  the  spermatic 
cord,  in  the  male;  the  round  ligament,  in  the  female.  The  cut  edges 
of  the  aponeurosis  should  be  seized  with  artery  forceps  and  separated 
freely  from  the  underlying  parts  with  the  finger.  The  spermatic 
cord  is  a  structure  as  big  around  as  the  little  finger.  It  is  made  up 
of  the  vas  deferens,  which  is  the  efferent  duct  of  the  testicle;  the 
artery  of  the  vas  deferens  and  the  cremasteric  artery,  and  their 
corresponding  veins;  the  spermatic  artery,  and  the  pampiniform 
venous  plexus.  As  these  structures  traverse  the  inguinal  canal  they 
are  all  bound  together  into  a  single  rounded  cord  by  a  strong  sheath 
of  fascia,  the  infundibular  process  of  the  transversalis  fascia.  De- 
scending upon  the  cord  are  also  seen  the  fibers  of  the  cremaster 
muscle,  which  are  derived  from  the  lower  edge  of  the  internal  oblique 
in  the  descent  of  the  testes.  The  cord  is  also  accompanied,  in  its 
course  through  the  inguinal  canal,  by  the  genital  branch  of  the 
genito-crural  nerve  and  the  inguinal  branch  of  the  ilio-inguinal 
nerve. 


Fig.  177. — The  Inguinal  Canal.  The  canal  has  been  laid  open  by 
splitting  the  aponeurosis  of  the  external  oblique  (A),  which  is  grasped  with 
the  artery  forceps  and  drawn  upward;  CT,  edge  of  the  internal  oblique 
muscle  (conjoined  tendon) ;  E,  dotted  line  represents  the  course  of  the  deep 
epigastric  artery,  which  is  located  beneath  the  transversalis  fascia;  P, 
Poupart's  ligament;  TF,  transversalis  fascia,  which  forms  the  posterior  wall 
of  the  inguinal  canal;  TL,  triangular  ligament,  which  is  given  off  from  the 
inner  end  of  PouDart's. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  425 

After  tlie  inguinal  canal  has  been  opened  by  splitting  the  apo- 
neurosis of  the  external  oblique,  the  free,  curved,  fleshy  edge  of  the 
internal  oblique  is  exposed  to  view.  This  muscle,  the  part  seen  here, 
arises  from  the  outer  half  of  Poupart's  ligament.  If  the  edge  of  this 
muscle  is  raised  and  drawn  upward  and  outward  for  a  short  distance, 
or  incised,  we  expose  the  transversalis  muscle,  which  lies  beneath  the 
internal  oblique.  That  portion  of  the  transversalis  which  is  thus 
exposed  arises  from  the  outer  third  of  Poupart's  ligament,  and  is 
covered  by  the  internal  oblique,  and  is  not  seen  until  the  edge  of 
this  latter  muscle  has  been  drawn  aside. 

Toward  the  outer  part  of  the  inguinal  canal  these  two  muscles, 
where  they  arise  from  Poupart's  ligament,  are  situated  for  a  short 
distance  in  front  of  the  spermatic  cord.  They  then  arch  inward 
above  the  cord,  and,  joining  with  each  other,  become  tendinous,  and, 
as  the  conjoined  tendon,  descend  behind  the  cord,  to  be  attached  to 
the  upper  surface  of  the  pubic  bone;  i.e.,  the  crest  and  the  pectin- 
eal line.  The  conjoined  tendon,  at  its  attachment  to  the  pubic 
bone,  is  placed  behind  the  external  ring,  and  participates  in  the 
formation  of  the  inner  part  of  the  posterior  wall  of  the  inguinal 
canal.  It  is  important  to  note  that  that  portion  of  the  posterior 
wall  of  the  inguinal  canal  which  is  included  between  the  arching 
free  edge  of  the  internal  oblique  muscle  above  and  Poupart's  liga- 
ment below  is  formed  by  the  transversalis  fascia  only.  This  fascia 
is  a  fibrous  layer  which  lines  the  whole  inner  surface  of  the  abdomen, 
including  the  posterior  surface  of  the  anterior  abdominal  wall,  and 
it  is  here  exposed  to  view  where  the  muscle  is  deficient;  i.e.,  between 
the  edge  of  the  internal  oblique  muscle  above  and  Poupart's  ligament 
below.  Through  the  outer  part  of  the  posterior  wall  of  the  inguinal 
canal  the  several  structures  which  go  to  make  up  the  spermatic  cord 
(round  ligament  in  the  female)  pass  forward  into  the  inguinal 
canal,  being  provided  with  a  strong,  fibrous  sheath,  which  is  known 
as  the  infundibular  process,  by  the  fascia  transversalis.  This  sheath 
incloses  the  several  elements  of  which  the  cord  is  composed,  and 
serves  to  bind  them  together  into  a  single  bundle,  which  traverses 
the  inguinal  canal  and  emerges  at  the  external  inguinal  ring.  The 
point  at  which  the  structures  which  constitute  the  spermatic  cord 
pass  forward  into  the  inguinal  canal  is  the  site  of  the  internal  ingui- 
nal ring.  The  internal  ring  is  an  opening  in  the  transversalis  fascia, 
which  is  located  half  an  inch  above  the  middle  of  Poupart's  liga- 
ment.    The  inguinal  canal  proper  has  no  internal  opening;    i.e.,  it 


426  HERNIA,  ETC. 

does  not  communicate  with  the  abdominal  cavity.  The  internal  in- 
guinal ring  is  really  the  mouth  of  the  infundibular  process,  which 
is,  in  reality,  the  sheath  that  is  provided  to  the  spermatic  cord  from 
the  transversalis  fascia. 

The  infundibular  process  is  a  glove-finger-like  diverticulum,  or 
pocket,  which  is  derived  from  the  fascia  transversalis,  being  pro- 
longed downward  into  the  bottom  of  the  scrotal  sac,  and,  through 
this,  the  testicle,  drawing  the  vas  deferens,  etc.,  after  it,  descends 
in  its  journey  from  the  abdomen  into  the  scrotum.  After  the  testis 
has  reached  the  bottom  of  the  scrotal  sac,  the  upper  part  of  this 
infundibular  process — i.e.,  the  part  which  corresponds  to  the  cord 
— contracts  and  shrinks  so  closely  around  the  structures  which  make 
up  the  cord,  and  which  are  contained  within  it,  that  its  cavity  is, 
in  this  way,  entirely  obliterated,  and  the  shrunken  infundibular 
process  remains  permanently  as  the  proper  fibrous  sheath  of  the 
spermatic  cord. 

The  lower  part,  however,  of  the  infundibular  process  remains 
permanently  unchanged  as  one  of  the  layers  of  the  scrotum. 

The  contraction  of  the  infundibular  process  about  the  upper 
part  of  the  cord  may  be  incomplete,  and  there  may  be  thus  left  a 
space  within  the  sheath  of  the  cord  (infundibular  process),  into 
which  the  point  of  the  finger  may  be  insinuated  from  within  the 
abdomen.  The  finger  under  these  circumstances  does  not  enter  the 
inguinal  canal,  but  passes  through  the  internal  ring  into  the  proper 
sheath  of  the  spermatic  cord.  The  mouth  of  the  infundibular  proc- 
ess, the  "internal  ring,"  may  be  best  studied  from  within  the  ab- 
domen, after  the  peritoneum,  which  lines  this  portion  of  the  ab- 
dominal wall,  has  been  stripped  away. 

Beneath  the  transversalis  fascia — i.e.,  the  posterior  wall  of  the 
inguinal  canal — is  found  the  parietal  layer  of  the  peritoneum,  with 
an  intervening  stratum  of  loose  connective  tissue,  containing  fat,  be- 
tween it  and  the  transversalis  fascia;  this  is  the  so-called  subperi- 
toneal connective  tissue  layer.  The  layer  of  peritoneum  which  lies 
behind,  or  rather  beneath,  the  posterior  wall  of  the  inguinal  canal 
presents  no  opening  whatever.  Within  the  abdomen,  about  the 
mouth  of  the  infundibular  process,  "internal  ring,"  the  parietal  peri- 
toneum is  adherent  to  the  transversalis  fascia,  and  may  show  a  slight 
bulging  into  the  neck  of  the  infundibular  process  (sheath  of  the 
cord). 

In  the  study  of  these  parts  the  deep  epigastric  artery  plays 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  427 

an  important  role.  This  artery  may  be  seen,  or  its  pulsation  felt, 
as  it  lies  beneath  the  transversalis  fascia  in  the  subperitoneal  con- 
nective tissue  between  the  transversalis  fascia  and  the  peritoneum. 
The  artery  is  accompanied  by  one  or  two  veins.  It  arises  from  the 
external  iliac  (femoral)  just  before  this  vessel  passes  out  of  the  ab- 
domen under  Poupart's  ligament,  and  ascends  obliquely  upward  and 
inward  toward  the  umbilicus  to  reach  the  outer  border  of  the  rectus 
muscle.  It  passes  across  the  posterior  wall  of  the  inguinal  canal 
about  the  middle,  and  so  divides  it  into  two  parts,  an  outer  and  an 
inner.  The  outer  part  of  the  posterior  wall  of  the  inguinal  canal, 
that  part  which  lies  external  to  the  deep  epigastric  artery,  is  formed 
by  the  transversalis  fascia  and  the  underlying  peritoneum,  and  pre- 
sents the  opening  through  which  the  structures  that  form  the 
spermatic  cord  (round  ligament)  leave  the  abdomen,  the  internal 
ring.  The  presence  of  this  orifice  tends  to  weaken  this  outer  part 
of  the  posterior  wall  of  the  inguinal  canal.  The  inner  portion  of  the 
posterior  wall  of  the  inguinal  canal,  that  part  which  lies  internal 
to  the  deep  epigastric  artery,  is  strengthened,  in  part,  by  several 
additional  layers.  From  before  backward  this  part  of  the  posterior 
wall  of  the  inguinal  canal  is  formed  of  the  triangular  ligament, 
conjoined  tendon,  transversalis  fascia,  and  parietal  peritoneum. 
This  inner  portion  of  the  posterior  wall  of  the  inguinal  canal  is, 
therefore,  much  more  secure  than  the  outer  part. 

A  hernia  that  protrudes  through  the  posterior  wall  of  the  in- 
guinal canal  external  to  the  deep  epigastric — i.e.,  one  which  passes 
through  the  "internal  ring"  and  works  its  way  downward  along  the 
cord — is  an  oblique,  or  external,  inguinal  hernia,  the  common  va- 
riety. In  those  cases  in  which  the  upper  part,  or  neck,  of  the  infun- 
dibular process  has  failed  to  become  tightly  contracted  around  the 
elements  of  the  cord  right  up  to  the  point  at  which  they  emerge 
from  the  abdomen,  the  predisposition  to  hernia  is,  without  doubt, 
more  pronounced,  and  this  is  especially  the  case  if,  in  addition,  the 
peritoneum,  which  is  normally  adherent  about  the  site  of  the  "in- 
ternal ring,"  shows  a  certain  degree  of  bulging  into  the  mouth  of 
the  patent  infundibular  process. 

A  hernia  that  bulges  forward  through  the  posterior  wall  of  the 
inguinal  canal  to  the  inner  side  of  the  deep  epigastric  artery  is  a 
direct,  or  internal,  inguinal  hernia.  Such  a  hernia  does  not  pass 
through  the  "internal  ring"  and  descend  along  the  course  of  the 
cord,  within  its  sheath  (infundibular  process),  but  bulges  directly 


42  S  HERNIA,  ETC. 

forward  into  the  inguinal  canal,  to  the  inner  side  of  the  cord,  and, 
besides  the  transversalis  fascia,  it  may  have  to  push  the  conjoined 
tendon,  etc.,  before  it,  or  else  force  its  way  between  the  fibers  of 
this  structure.  These  accessory  structures  form  a  strong  barrier 
against  the  formation  of  a  direct  hernia,  which  variety  is  much 
less  common  than  the  oblique. 

In  the  female  the  inguinal  canal  and  rings  are  all  less  well  de- 
veloped than  in  the  male.  The  round  ligament  is  a  thin  structure, 
often  difficult  to  find.  After  passing  through  the  inguinal  canal 
it  emerges  from  the  external  ring,  and  is  then  lost  in  the  connect- 
ive tissue  about  the  external  ring  and  in  the  labia  majora. 

Inguinal  hernia  is  comparatively  infrequent  in  the  female. 
When  it  occurs,  it  is  analogous  to  that  in  the  male,  and  may  de- 
scend into  the  labia  majora. 

The  Descent  of  the  Testes.  —  The  testes  (ovaries  in  the 
female)  are  developed  within  the  abdomen  from  the  Wolffian  body, 
and  in  early  foetal  life  they  are  situated  in  the  back  part  of  the 
abdominal  cavity  near  the  kidneys.  They  lie  not  within  the  peri- 
toneal cavity,  but,  like  the  kidney,  behind  the  peritoneum,  which 
is  adherent  to  their  front  surface.  From  this  position,  the  testes, 
during  the  later  months  of  foetal  life,  gradually  descend.  They  de- 
scend behind  the  peritoneum  and  enter  the  infundibular  process 
through  its  mouth,  the  "internal  ring."  Finally,  during  the  last 
month  of  intra-uterine  life  they  arrive  at  their  normal  destination, 
the  bottom  of  the  scrotal  pouch. 

The  ovaries  descend  in  an  analogous  manner,  but  do  not  pass 
out  of  the  abdominal  cavity. 

Preparatory  to  the  descent  of  the  testis  there  is  a  pouch-like 
bulging  of  the  lower  part  of  the  anterior  abdominal  wall  in  either 
inguinal  region.  A  shallow  pouch  is  thus  formed  on  either  side, 
which  gradually  becomes  deeper,  and  finally  the  two  join  together 
in  the  middle  line  to  form  the  scrotum.  Each  of  these  pouches  is 
lined  on  its  internal  aspect  by  a  sac-like  prolongation  from  the  trans- 
versalis fascia  (infundibular  process).  These  pouches  are  empty 
and  ready  to  receive  the  testes. 

Reaching  from  the  testis  as  it  lies  within  the  abdomen,  down- 
ward into  the  bottom  of  the  infundibular  process  (scrotum),  there 
is  a  musculo-fibrous  structure,  the  gubernaculurn  of  Hunter.  It 
serves  to  lead  the  testis  down  into  the  scrotal  sac. 

About  the  sixth  month  of  foetal  life  the  descent  of  the  testis 


1.  At  Sixth  Month. 

Testis  located  in  the  back  part  of  the  abdominal  cavity,  covered  by  the  peritoneum  upon 

its  anterior  aspect. 
G,  gubernaculum  of  Hunter. 

IP,  infundibular  process  of  the  transversalis  fascia. 
P,  peritoneum  lining  the  interior  of  abdominal  cavity. 
S,  scrotum. 
T,  testis. 

TF,  transversalis  fascia. 
VD,  vas  deferens. 

2.  At  the  Seventh  Month. 

The  testis  has  descended  into  the  inguinal  region  toward  the  mouth  of  the  infundibular 
process — future  internal  inguinal  ring. 

3.  At  the  Eighth  Month. 

The  testis  has  entered  the  infundibular  process,  carrying  a  process  of  the  peritoneum 

with  it. 
VP,  vaginal  process  of  peritoneum. 

4.  At  Ninth  Month. 

Testis  has  reached  the  bottom  of  the  infundibular  process, — scrotum, — carryin g  process 
of  peritoneum  with  it. 

•5.    Third  to  Fourth  Week  after  Birth. 

Testis  is  located  in  the  bottom  of  the  infundibular  process — scrotum.  Obliteration 
has  begun  in  the  vaginal  process. 

«.    Several  Months  after  Birth. 

Normal  adult  condition. 

Testis  rests  in  bottom  of  infundibular  process — scrotum.  The  vaginal  process  which 
accompanied  the  testis  in  its  descent  has  become  obliterated  except  for  that  portion 
of  its  extent  which  corresponds  to  the  testis.  This  remains  as  the  tunica  vaginalis 
testis. 

CT,  cavity  of  tunica  vaginalis  testis. 


Fig.  178. — Descent  of  the  Testis. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  429 

begins.  The  gubernaculum  contracts  and  draws  the  testis  downward 
toward  the  inguinal  region.  About  the  seventh  month  the  testis 
arrives  at  the  "internal  ring,"  the  wide-open  mouth  of  the  infun- 
dibular process.  The  testis  then  passes  into  the  infundibular  proc- 
ess, and,  as  it  does  so,  it  brings  a  bag-like  process  of  the  peritoneum, 
which  is  adherent  to  it,  with  it.  This  is  called  the  vaginal  process 
of  the  peritoneum.  At  the  eighth  month  the  testis  is  found  in  the 
infundibular  pouch,  together  with  the  vaginal  process  of  the  peri- 
toneum, which  accompanies  it,  and  during  the  last  month  of  intra- 
uterine life  it  is  found  at  the  bottom  of  the  infundibular  pouch,  the 
scrotum,  together  with  its  vaginal  peritoneal  process. 

The  testis  may  be  interrupted  in  its  journey  into  the  scrotum 
at  any  point,  and  may  remain  stationary  either  in  the  abdomen  or 
in  the  inguinal  canal.  This  condition  occasionally  complicates  con- 
genital hernia.  After  the  testis  has  reached  the  bottom  of  the 
scrotal  sac,  the  peritoneal  pouch,  which  accompanied  it,  becomes, 
for  that  part  of  its  extent  which  corresponds  to  the  vas  deferens, 
gradually  obliterated.  This  process  of  obliteration  commences  in 
the  middle  of  the  tube  and  extends  upward  toward  its  abdominal 
orifice,  and  downward  toward  the  testis,  and,  in  the  adult,  this  ob- 
literated portion  of  the  vaginal  process  is  represented  only  by  a 
fibrous  strand  that  is  found,  together  with  the  vas  deferens,  etc., 
inclosed  within  the  proper  sheath  of  the  cord. 

The  lower  part  of  the  vaginal  process,  that  portion  which  corre- 
sponds to  the  testis,  remains  permanently  as  the  tunica  vaginalis 
testis.  At  birth  the  canal  of  the  vaginal  process  is  still  pervious, 
but  very  much  shrunken,  and  becomes  rapidly  obliterated  during 
the  first  few  weeks  of  extra-uterine  life. 

If  the  peritoneal  pouch,  the  vaginal  process,  which  accompanies 
the  testis  in  its  descent,  remains  pervious  after  birth  throughout 
its  whole  extent,  and,  if  its  orifice  is  large  enough  to  permit,  a  coil 
of  intestine  may  enter;   and  we  shall  then  have  a  congenital  hernia. 

In  the  female  the  round  ligament  is  the  remains  of  the  guber- 
naculum. The  ovary  descends  like  the  testis,  but  does  not  leave  the 
abdominal  cavity;  it  remains  in  the  pelvis.  It  does,  however,  ex- 
ceptionally leave  the  abdominal  cavity,  and  may  then  be  found  in 
the  labia  majora.    Congenital  hernia  is  uncommon  in  the  female. 

To  recapitulate:  There  are  two  varieties  of  inguinal  hernia, 
the  direct,  or  internal,  and  the  oblique,  or  external.  The  direct 
is  always  acquired,  and  is  less  common  than  the  indirect.     In  this 


430  HERNIA,  ETC. 

variety  a  pouch  of  peritoneum  (the  hernial  sac) — containing,  for  ex- 
ample, a  loop  of  gut — simply  forces  that  part  of  the  posterior  wall 
of  the  inguinal  canal  that  lies  to  the  inner  side  of  the  deep  epigastric 
anery  before  it  into  the  inguinal  canal,  and  finally  down  through 
the  external  ring. 

The  oblique  variety  may  be  either  congenital  or  acquired. 

A  congenital  hernia  is  due  to  the  absence  of  obliteration  in  the 
vaginal  peritoneal  process.  If  this  process  remains  patent  through- 
out its  entire  length,  the  hernial  contents — for  example,  a  coil  of  gut 
— simply  drop  into  the  open  pouch,  and  we  have  the  usual  form  of 
congenital  hernia. 

An  acquired  oblique  hernia  is  produced  after  the  vaginal  process 
has  become  completely  and  permanently  obliterated.  In  this  variety 
the  contents — for  example,  a  coil  of  gut — must  force  an  entirely  new 
pouch  of  peritoneum,  which  constitutes  the  hernial  sac,  before  it. 
This  peritoneal  sac  enters  the  mouth  of  the  infundibular  process 
("internal  ring")  like  a  wedge,  and  works  its  way  downward  along  the 
spermatic  cord,  inclosed  within  the  sheath  of  the  cord  (infundibular 
process),  which  it  simply  distends;  or  else,  after  passing  through  the 
internal  ring  into  the  infundibular  process  (sheath  of  the  cord),  it 
causes  a  bulging  of  a  circumscribed  portion  of  the  sheath  of  the  cord, 
with  the  result  that  a  pocket,  or  pouch,  is  formed,  which  is  really 
an  offshoot  from  the  proper  sheath  of  the  cord,  and  in  this  pouch  the 
hernial  peritoneal  sac  is  found,  together  with  the  hernial  contents. 

An  acquired  hernia  may  traverse  the  whole  length  of  the  in- 
guinal canal  and  enter  the  scrotum,  but  its  sac  is  always  entirely 
distinct  from  the  original  vaginal  peritoneal  process,  and  its  con- 
tents are  never  to  be  found  in  the  same  cavity  with  the  testis,  as 
is  the  case  in  the  congenital  variety. 

A  partial  obliteration  of  the  vaginal  process  of  the  peritoneum 
may  occur,  and  we  may  then  have  an  infantile,  or  encysted,  hernia. 
In  this  case  the  vaginal  process  is  occluded  at  or  near  its  mouth, 
but  remains  open  throughout  a  part  of  its  extent  below.  We  then 
have  a  hernia,  with  its  own  newly  acquired  peritoneal  sac,  like  an 
ordinary  acquired  hernia,  passing  through  the  internal  ring  and 
downward  within  the  sheath  of  the  cord,  pushing  the  closed,  but 
unobliterated,  vaginal  peritoneal  process  in  front  of  it.  When  such  a 
hernia  is  operated  upon,  it  looks  as  though  there  were  two  separate 
and  distinct  sacs.  The  unobliterated  vaginal  process,  within  which 
the  testis  is  found,  is  entered  first,  and  then  a  second  serous  sac,  the 


Fig.  179. — Normal  Condition  of  Inguinal  Region,  Scrotum,  etc.  Testis  in 
bottom  of  scrotum  and  vaginal  process  obliterated.  CT,  cavity  of  tunica 
vagina  is  testis;  IN,  intestine  within  abdominal  cavity;  IR,  internal  inguinal 
ring — the  mouth  of  the  original  infundibular  process  of  the  transversalis 
fascia;  P,  peritoneum  lining  abdominal  cavity;  TF,  transversalis  fascia; 
YD,  va     deferens;    VP,  vaginal  process  of  peritoneum — obliterated. 


Fig.  180.— Condition  of  Parts  in 
Presence  of  a  Congenital  (Oblique  In- 
guinal) Hernia.  Note  that  the  vaginal 
process  is  patent,  unobliterated,  and 
that    a    coil    of    intestine    has    entered. 


Fig.  181. — Condition  of  Parts  in 
Presence  of  an  Acquired  Oblique  In- 
guinal Hernia.  Note  that  the  vaginal 
process  (VP)  is  obliterated  and  that  a 
coil  of  intestine  has  pushed  its  way 
down  into  the  original  infundibular 
process  (sheath  of  the  spermatic  cord), 
driving  a  new  process  of  peritoneum  (S) 
before  it.  This  peritoneal  process  forms 
the  sac  of  the  hernia. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  431 

true  hernial  sac,  is  met  with  and  incised,  and  within  this  the  hernial 
contents  are  encountered. 

The  Femoral  Eegion. — The  area  immediately  below  Poupart's 
ligament  is  known  as  the  femoral  region. 

The  Fascia  Lata  is  exposed  after  the  skin  and  superficial  fascia 
have  been  removed.  This  is  a  strong,  aponeurotic  layer  which  en- 
tirely surrounds  the  muscles  of  the  thigh,  and  serves  to  bind  them 
into  a  compact  mass.  It  is  attached  above,  in  front,  to  the  whole 
length  of  Poupart's  ligament,  from  the  pubic  spine  to  the  anterior 
superior  iliac  spine;  externally,  to  the  crest  of  the  ilium;  behind, 
to  the  sacrum;  and,  internally,  to  the  rami  of  the  pubes  and  ischium. 

Just  below  Poupart's  ligament,  where  the  internal  saphenous 
vein  enters  the  femoral  vein,  the  fascia  lata  presents  an  oval  open- 
ing, the  saphenous  opening.  It  is  only  exposed  after  the  cribriform 
fascia  (that  part  of  the  deep  layer  of  the  superficial  fascia  which  is 
attached  to  the  margins  of  the  saphenous  opening)  has  been  re- 
moved. The  outer  margin  of  the  saphenous  opening  is  sharp  and 
curved,  and  was  called  by  Allan  Burns  the  falciform  process.  If 
the  falciform  process  is  traced  upward  and  inward,  it  is  found  to  be 
continuous  with  the  inner  end  of  Poupart's  ligament  and  with  Gim- 
bernat's  ligament,  some  of  its  fibers  being  attached,  with  this  latter 
ligament,  to  the  pubic  bone.  Below,  the  falciform  process  is  seen 
to  curve  inward  underneath  the  internal  saphenous  vein,  becoming 
continuous  here  with  that  part  of  the  fascia  lata  which  covers  the 
pectineus  muscle  (pubic  portion  of  the  fascia  lata).  The  free  edge  of 
the  falciform  process,  and  that  part  of  the  fascia  lata  external  to 
it,  cover  the  femoral  sheath  upon  its  anterior  aspect,  and  are  known 
as  the  "iliac  portion"  of  the  fascia  lata.  It  is  attached  above  to  the 
whole  length  of  Poupart's  ligament,  and  externally  is  continuous 
with  the  sheath  of  the  sartorius  muscle. 

That  portion  of  the  fascia  lata  upon  which  the  internal  saphe- 
nous vein  rests,  and  which  covers  the  pectineus  muscle,  may  be  traced 
upward,  under  Poupart's  ligament,  as  far  as  the  ilio-pectineal  line,  to 
which  it  is  attached,  and  from  which  the  pectineus  muscle  arises. 
This  is  known  as  the  "pubic  portion"  of  the  fascia  lata.  Beneath  the 
femoral  vessels  this  pubic  portion  of  the  fascia  lata  is  continuous, 
externally,  with  the  fascia  which  covers  the  ilio-psoas  muscle  (fascia 
iliaca).  Above,  under  Poupart's  ligament,  this  fascia,  which  covers 
the  pectineus  muscle,  is  thickened,  and  is  known  as  the  pubic  liga- 
ment of  Cooper.    These  two  portions  of  the  fascia  lata,  the  iliac  and 


432  HERNIA,  ETC. 

pubic  portions,  are  so  arranged  that  a  slit-like  opening,  the  saphenous 
opening,  exists  between  them,  and  through  this  the  internal  saphe- 
nous vein  joins  the  femoral  vein. 

The  femoral  vessels,  inclosed  within  their  sheath,  are  sand- 
wiched in  between  these  two  portions  of  the  fascia  lata,  resting 
behind  upon  the  fascia  which  covers  the  pectineus  and  ilio-psoas 
muscles,  and  covered  in  front  by  the  iliac  portion  of  the  fascia  lata. 
The  two  portions  of  the  fascia  lata,  which  have  just  been  described, 
the  iliac  and  pubic  portions,  are  simply  parts  of  one  and  the  same 
fascia,  and  are  seen  to  be  directly  continuous  with  each  other,  below 
the  saphenous  opening  upon  the  front  of  the  thigh.  The  pubic 
portion  of  the  fascia  lata,  which  corresponds  to  the  pectineus  muscle, 
is,  as  already  said,  continuous  externally,  behind  the  sheath  of  the 
femoral  vessels,  with  the  iliac  fascia,  which  invests  the  ilio-psoas 
muscle.  One  should  not  confuse  the  names  "iliac  portion  of  the 
fascia  lata"  with  "iliac  fascia." 

The  Space  Beneath  Poupart's  Ligament.  —  Through  this  space 
the  ilio-psoas  muscle  and  the  anterior  crural  nerve  and  the  femoral 
vessels  pass  out  of  the  abdomen  into  the  thigh. 

The  ilio-psoas  muscle,  with  the  anterior  crural  nerve,  occupies 
the  outer  part  of  the  space.  The  ilio-psoas  muscle  is  a  thick  mass 
of  muscle  which  has  its  origin  within  the  abdomen  from  the  iliac 
fossa,  bodies  of  the  lumbar  vertebras,  etc.  It  consists  of  the  psoas 
and  iliacus  muscles,  and  passes  downward  under  Poupart's  ligament 
into  the  thigh,  where  it  is  attached  to  the  lesser  trochanter  of  the 
femur  and  to  the  surface  of  the  bone  immediately  below  this. 

Within  the  abdomen  the  ilio-psoas  muscle  is  covered  by  a  thick 
fascia,  the  fascia  iliaca,  which  is  attached  to  the  bodies  of  the  lumbar 
vertebra?  and  to  the  sacrum,  to  the  crest  of  the  ilium,  and  to  the 
brim  of  the  pelvis. 

At  Poupart's  ligament,  that  part  of  the  iliac  fascia  which  covers 
the  outer  portion  of  the  ilio-psoas  muscle — i.e.,  corresponding  to  the 
outer  third  of  Poupart's  ligament — does  not  pass  down  into  the 
thigh  with  the  muscle,  but  is  attached  to  Poupart's  ligament,  whence 
it  is  reflected  upward,  becoming  continuous  with  the  transversalis 
fascia,  which  lines  the  whole  posterior  surface  of  the  anterior  ab- 
dominal wall.  Internal  to  this,  however,  corresponding  to  the  inner 
portion  of  the  ilio-psoas  muscle,  the  fascia  which  covers  the  muscle 
passes  with  the  muscle,  underneath  Poupart's  ligament,  down  into  the 
thigh,  and  in  the  upper  part  of  the  thigh  is  continuous,  behind  the 


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SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  433 

sheath  of  the  femoral  vessels,  with  the  fascia  which  covers  the  pectin- 
eus  muscle  (pubic  portion  of  the  fascia  lata).  Immediately  beneath 
Poupart's  ligament  the  iliac  fascia  is  thickened,  and  this  thickened 
portion  is  called  the  ilio-pectineal  ligament.  This  is  not  an  isolated 
ligamentous  band  of  fibers,  but  simply  a  thickened  portion  of  the 
fascia  iliaca  as  it  passes  with  the  ilio-psoas  muscle  under  Poupart's 
ligament  into  the  thigh.  It  extends  from  the  junction  of  the  outer 
and  middle  thirds  of  Poupart's  ligament  downward  and  inward  to 
the  ilio-pectineal  eminence,  and  serves  thus  to  divide  the  space  un- 
derneath Poupart's  ligament  into  two  portions:  an  outer,  the  ilio- 
psoas space,  which  contains  the  ilio-psoas  muscle  and  the  anterior 
crural  nerve,  and  an  inner  and  upper,  the  femoral  space,  through 
which  the  femoral  vessels  pass  from  the  abdomen  into  the  thigh. 

The  femoral  space  is  bounded  above  by  Poupart's  ligament; 
below,  it  is  bounded  externally  by  the  ilio-pectineal  ligament,  and, 
internally,  by  the  pubic  ligament  of  Cooper.  The  so-called  pubic 
ligament  of  Cooper  is  simply  the  thickened  upper  portion  of  the 
fascia  which  covers  the  pectineus  muscle.  Internally,  the  space  is 
bounded  by  the  sharp,  curved  edge  of  Gimbernat's  ligament.  The 
space  is  limited  externally  by  the  junction  of  Poupart's  ligament 
and  the  ilio-pectineal  ligament. 

The  Femoral  Sheath. — As  the  femoral  vessels  pass  into  the  thigh, 
through  the  femoral  space,  they  are  inclosed  in  a  special  connective 
tissue  sheath,  and  rest  upon  the  ilio-psoas  and  pectineus  muscles. 
The  femoral  sheath  is  a  funnel-shaped  connective  tissue  envelope 
which  is  prolonged  downward  from  the  margins  of  the  femoral  space, 
inclosing  the  vessels  as  they  pass  into  the  thigh.  Corresponding  to 
its  commencement  at  Poupart's  ligament,  the  femoral  sheath  is  wide- 
mouthed,  and  attached  all  around  to  the  margins  of  the  femoral 
space.  Above,  it  is  attached  to  Poupart's  ligament;  below,  to  the 
ilio-pectineal  ligament  (thickened  portion  of  the  fascia  covering  the 
ilio-psoas  muscle)  and  to  the  ligament  of  Cooper  (thickened  upper 
portion  of  the  fascia  that  covers  the  pectineus  muscle).  Internally, 
it  is  attached  to  the  edge  of  Gimbernat's  ligament.  The  femoral 
sheath  is  continued  but  a  short  distance  downward  upon  the  femoral 
vessels,  becoming  narrow  and  contracted  below,  and  closely  applied 
to  the  walls  of  the  vessels. 

The  femoral  sheath  is  divided  into  three  compartments,  which 
are  entirely  separate  and  distinct  from  each  other,  by  connective 
tissue    septa.      In    the    outer    compartment    the    femoral    artery   is 


434  HERNIA,  ETC. 

lodged;  in  the  middle,  the  femoral  vein;  the  inner  compartment 
contains  a  lymphatic  gland  and  some  loose  connective  tissue,  and 
gives  passage  to  the  lymphatic  vessels  that  enter  the  abdomen  from 
the  lower  extremity.  This  space,  the  inner,  is  called  the  crural  canal. 
It  is  inclosed  within  the  femoral  sheath,  and  reaches  from  Gim- 
bernat's  ligament  downward  upon  the  inner  side  of  the  femoral  vein 
as  far  as  the  junction  of  the  internal  saphenous  vein  with  the  fem- 
oral, at  which  point  the  crural  canal  ceases  to  exist,  because  here  the 
femoral  sheath  is  applied  directly  to  the  wall  of  the  femoral  vein. 

The  orifice  of  this  crural  space,  or  canal,  is  called  the  crural 
ring.  The  crural  ring  is  bounded  above  by  Poupart's  ligament;  be- 
low, by  the  pectineus  muscle  and  the  fascia  which  covers  it,  and 
which  is  here  thickened  and  called  the  pubic  ligament  of  Cooper; 
internally,  by  Grimbernat's  ligament;  and,  externally,  by  the  femoral 
vein.  A  femoral  hernia,  as  it  descends  into  the  thigh,  usually  oc- 
cupies this  crural  canal,  lying  to  the  inner  side  of  the  femoral  vein, 
and,  just  above  the  junction  of  the  internal  saphenous  vein  with 
the  femoral  vein,  where  the  crural  canal  terminates,  it  presents  in 
the  saphenous  opening. 

Study  of  the  Inguinal  and  Femoral  Eegions  from  Within  the 
Abdomen. — To  examine  these  regions  from  within  the  abdomen,  an 
incision  is  made  through  the  anterior  abdominal  wall,  on  either  side, 
passing  from  the  umbilicus  outward  and  then  downward  to  a  point 
just  external  to  the  anterior  superior  spine  of  the  ilium. 

The  Inguinal  Eegion. — The  bladder  is  seen  to  occupy  the  an- 
terior median  portion  of  the  true  pelvis,  and  when  moderately  full 
reaches  as  high  as  the  symphysis.  It  will  be  observed  that  the 
peritoneum  which  covers  the  bladder  is  continued  forward  from  the 
fundus  of  that  organ  over  on  to  the  posterior  surface  of  the  ante- 
rior wall  of  the  abdomen,  where  it  presents  several  folds,  or  ridges, 
which  are  caused  by  the  projection  of  prominent  underlying  struct- 
ures. These  several  ridges,  or  plicae,  converge  in  a  direction  upward, 
toward  the  umbilicus,  and  include  between  them  areas  which  are 
more  or  less  depressed,  and  which  are  called  foveas.  In  the  middle  line, 
reaching  from  the  summit  of  the  bladder  upward  to  the  umbilicus,  the 
peritoneum  is  raised  in  the  shape  of  a  fold  by  the  superior  ligament  of 
the  bladder,  the  remains  of  the  fcetal  urachus.  External  to  this,  pass- 
ing from  either  side  of  the  body  of  the  bladder  upward  to  the  um- 
bilicus, there  is  a  fold,  beneath  which  the  obliterated  hypogastric 
artery  runs.    Still  more  externally  there  is  another  fold,  which  corre- 


Fig.  184.— The  Pelvis  and  Ligaments  of  the  Ilio-pubic  Region.  FS,  femoral 
space;  G,  Gimbernat's  ligament:  IP,  ilio-pectineal  ligament;  IPS,  ilio-psoas 
space;    P,  Poupart's  ligament;    PS,  pubic  spine. 


Fig.  1S5. — Femoral  Space.  Femoral  vessels  and  sheath  as  they  pass  under 
Poupart's  ligament  have  been  cleared  away.  Poupart's  ligament  lifted  upon 
hook.  The  iliacus  and  psoas  muscles  are  covered  by  their  fascia,  the  fascia 
iliaca;  IP,  ilio-pectineal  ligament— thickened  portion  of  the  fascia  that  invests 
the  ilio-psoas  muscle;  LP,  Poupart's  ligament;  P,  pubic  ligament  of  Cooper- 
upper  thickened  part  of  the  fascia  that  covers  the  pectineus  muscle. 


Fig.  186.— Deep  Femoral  Region — the  Femoral  Vessels,  etc.,  Cut  Across  as  they 
Emerge  Under  Poupart's  Ligament,  AC,  anterior  crural  nerve;  CT,  edge  of  the  con- 
joined tendon;  CR,  crural  ring;  E,  dotted  line  indicates  the  course  of  the  deep 
epigastric  artery;  FS,  femoral  sheath;  G,  Gimbernat's  ligament;  IP,  ilio-pectineal 
ligament;  P,  Poupart's  ligament;  Pit,  pectineus  muscle.  This  muscle  rests  upon  the 
pubic  bone  and  is  covered  by  its  fascia, — the  pectineal  fascia, — which  is  somewhat 
thickened  immediately  beneath  Poupart's  ligament,  where  it  is  known  as  the  pubic 
ligament  of  Cooper.  It  will  be  noticed  that  the  femoral  sheath  is  divided  into  three 
compartments:  the  outer  for  the  femoral  artery;  the  middle  for  the  femoral  vein;  the 
inner  (CR)  is  the  crural  ring,  the  mouth  of  the  crural  canal. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  435 

sponds  to  the  course  of  the  deep  epigastric  artery;  this  is  a  large  vessel 
given  off  from  the  external  iliac  (femoral)  just  before  it  passes  out  of 
the  abdomen  under  Poupart's  ligament,  and  is  accompanied  by  one  or 
two  veins.  The  peritoneal  folds  are  named,  respectively,  the  plica 
vesico-umbilicalis  media,  corresponding  to  the  urachus,  in  the  middle 
line;  the  plica  vesico-umbilicalis  lateralis,  corresponding  to  the  oblit- 
erated hypogastric  artery;  and  the  plica  epigastrica,  corresponding  to 
the  epigastric  artery  and  vein.  Between  these  peritoneal  folds,  or 
plicse,  are  the  foveas,  already  mentioned,  which  are  deeper  in  some 
subjects  than  in  others.  External  to  the  plica  epigastrica  is  the  fovea 
inguinalis  externa.  Between  the  plica  epigastrica  and  the  plica  vesico- 
umbilicalis  lateralis  is  the  fovea  inguinalis  interna.  Between  the  plica 
vesico-umbilicalis  lateralis  and  the  plica  vesico-umbilicalis  media  is 
the  fovea  supravesicalis. 

The  Fovea  Inguinalis  Externa. — After  the  peritoneum  has  been 
stripped  off  from  this  area,  and  some  loose  connective  tissue  (sub- 
peritoneal connective  tissue)  which  lies  beneath  it  has  been  removed, 
we  expose  the  transversalis  fascia.  This  fascia  presents  the  opening 
into  the  infundibular  process,  the  so-called  "internal  ring,"  which  is 
located  about  half  an  inch  above  the  middle  of  Poupart's  ligament. 
The  vas  deferens,  spermatic  artery,  veins,  etc.,  structures  of  which 
the  spermatic  cord  is  formed  (in  the  female,  the  round  ligament), 
pass  into  this  opening.  The  lower,  inner,  margin  of  the  internal 
ring  presents  a  distinct,  sharp,  crescentic  edge.  A  probe  or  the  finger 
can  be  introduced  into  the  internal  ring,  and  may  be  insinuated  for 
a  greater  or  less  distance  into  the  sheath  of  the  spermatic  cord, 
infundibular  process.  About  the  internal  ring  the  peritoneum  is 
more  or  less  plaited  upon  itself,  and  is  adherent  to  the  margins  of 
the  ring,  and  may  bulge  for  a  certain  distance  into  it.  A  fibrous 
cord  passes  from  the  peritoneum  into  the  internal  ring,  and  may  be 
traced  downward  into  the  infundibular  process  along  with  the  other 
constituents  of  the  spermatic  cord.  This  fibrous  band,  or  string, 
represents  the  shrunken,  obliterated  vaginal  process  of  peritoneum 
which  accompanies  the  testis  in  its  descent  into  the  scrotum.  Di- 
rected upward  and  inward  toward  the  umbilicus,  and  passing  to  the 
inner  side  of  the  internal  ring  is  the  deep  epigastric  artery,  with  its 
accompanying  vein.  If  a  hernial  protrusion  occurs  in  this  location, 
the  process  of  peritoneum  which  forms  the  sac  of  the  hernia  forces 
its  way  through  the  internal  ring  (to  the  outer  side  of  the  deep 
epigastric),  and  gradually  works  its  way  downward  within  the  fibrous 


436 


HERNIA,  ETC. 


Fig.  187.— The  Inguinal  and  Femoral  Regions  from  Within  the  Abdomen.  Upon 
the  right  side  the  peritoneum  has  been  stripped  off,  exposing  the  transversalis  fascia. 
AC,  anterior  crural  nerve  imbedded  in  the  ilio-psoas  muscle;  D,  semilunar  fold  of 
Douglas— the  lower  edge  of  the  posterior  layer  of  the  sheath  of  rectus;  E,  deep  epi- 
gastric artery;  E1,  plica  epigastrica  (the  deep  epigastric  vessels  are  situated  beneath 
this  fold);  F.I.,  cut  edge  of  the  fascia  iliaca,  which  invests  the  ilio-psoas  muscle;  OL, 
Gimbernat's  ligament;  H,  obliterated  hypogastric  artery;  I.E.,  fovea  inguinalis  externa; 
/./.,  fovea  inguinalis  interna;  IL,  sawn  surface  of  the  ilium;  IPL,  ilio-pectineal  liga- 
ment, a  thickened  portion  of  the  iliac  fascia;  P,  cut  edge  of  the  peritoneum;  P. I., 
cut  edge  of  the  ilio-psoas  muscle;  PL,  Poupart's  ligament;  PM,  pectineus  muscle  cov- 
ered by  its  fascia,  which  is  here  somewhat  thickened  and  is  known  as  the  pubic  liga- 
ment of  Cooper;  8~V,  fovea  supravesical ;  Y.L.,  plica  vesico-umbilicalis  lateralis  (the 
obliterated  hypogastric  artery  lies  beneath  this  fold);  V.M.,  plica  vesico-umbilicalis 
media  (the  urachus,  which  reaches  from  the  fundus  of  the  bladder  to  the  umbilicus,  is 
situated  beneath  the  fold).  Above  the  middle  of  Poupart's  ligament  there  is  an  opening 
in  the  transversalis  fascia — internal  inguinal  ring — mouth  of  the  infundibular  process. 
The  vas  deferens  and  other  component  parts  of  the  spermatic  cord  which  pass  in  and 
out  of  the  abdomen  through  this  orifice  have  been  cut  short  in  the  picture;  this  open- 
ing is  the  exit  for  indirect  inguinal  hernia.  Beneath  Poupart's  ligament  the  femoral 
vessels,  inclosed  with  their  sheath,  are  seen.  These  structures  have  been  divided  close 
to  Poupart's  ligament.  The  femoral  sheath  occupies  the  space  described  as  the  femoral 
space,  and  is  divided  into  three  compartments— the  outer  for  the  artery  and  the  middle 
for  the  vein;    the  orifice  of  the  inner  compartment  is  called  the  crural  ring. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  437 

sheath  of  the  cord,  which  is  the  remains  of  the  original  infun- 
dibular process,  and  we  then  have  a  typical  external,  or  oblique, 
inguinal  hernia.  The  coverings  of  this  variety  of  hernia,  from 
within  outward,  are,  besides  its  peritoneal  sac,  the  infundibular  fascia 
(pouch  derived  from  fascia  transversalis),  cremaster  muscle  and  fascia, 
deep  layer  of  the  superficial  fascia  (spermatic  fascia),  superficial  layer 
of  the  superficial  fascia  (fat),  and  the  skin. 

If  a  congenital  hernia  is  present,  the  vaginal  peritoneal  process 
which  accompanied  the  testis  in  its  descent  into  the  scrotum  is  found 
patent,  unobliterated,  reaching  downward  through  the  internal  ring 
and  along  the  cord  within  its  sheath  (infundibular  process)  to  the 
bottom  of  the  scrotum. 

The  coverings  of  a  congenital  hernia  are  the  same  as  those  given 
for  the  oblique,  or  external,  acquired  variety.  The  difference  be- 
tween the  oblique  acquired  and  the  congenital  is  that  the  acquired 
must  form  a  peritoneal  sac  for  itself,  whereas  the  congenital  finds 
its  sac  already  present;  i.e.,  the  unobliterated  vaginal  peritoneal 
process. 

The  Fovea  Inguinalis  Interna. — This  is  the  space  between  the 
plica  epigastrica  and  the  plica  vesico-umbilicalis  lateralis.  After  the 
peritoneum  has  been  stripped  away  from  this  part  we  expose  the  trans- 
versalis fascia.  The  fovea  inguinalis  interna  is  the  part  which  is  in- 
volved in  direct  inguinal  hernia.  It  presents  no  opening.  In  the 
event  of  a  direct  inguinal  hernia,  a  bulging  or  pouching  of  this  part 
of  the  posterior  wall  of  the  inguinal  canal  occurs,  and  the  hernial 
sac,  composed  of  the  parietal  peritoneum,  will  have  as  coverings, 
from  within  outward,  the  various  layers  that  form  this  part  of  the 
posterior  wall  of  the  inguinal  canal,  viz.:  the  fascia  transversalis, 
the  conjoined  tendon,  and  the  triangular  ligament,  and,  in  addition, 
the  deep  layer  of  the  superficial  fascia  (spermatic  fascia),  the  super- 
ficial layer  of  the  superficial  fascia  (fat),  and  the  skin. 

The  neck  of  the  sac  in  a  direct  inguinal  hernia  lies  to  the  inner 
side  of  the  deep  epigastric  vessels. 

Fovea  Supravesical^.  —  This  is  the  space  between  the  plica 
vesico-umbilicalis  lateralis  and  media.  Its  floor  is  formed  by  the 
rectus  muscle.  This  region  is  of  but  little  surgical  interest,  and  is 
not  the  site  of  hernial  protrusions. 

The  Femoral  Eegion. — Below  Poupart's  ligament  we  have  the 
femoral  region.  This  part  is,  at  times,  depressed,  and  is  called  the 
fessa  cruralis.     If  we  dissect  away  the  peritoneum,  we  expose  Pou- 


438  HERNIA,  ETC. 

part's  ligament,  passing  from  the  anterior  superior  spinous  process 
of  the  ilium  inward  and  downward,  to  be  attached  to  the  spine  of 
the  pubes.  From  the  lower  border  of  Poupart's  ligament,  just  be- 
fore its  attachment  to  the  pubic  spine,  a  triangular  band  of  fibers, 
which  is  attached  to  the  ilio-pectineal  line,  is  given  off.  This  is 
called  Gimbernat's  ligament.  Its  sharp  outer  edge  may  be  readily 
felt. 

Between  Poupart's  ligament  and  the  pubic  bones  there  is  a  large 
space  through  which  the  ilio-psoas  muscle  and  anterior  crural  nerve 
and  the  femoral  vessels  pass  into  the  thigh.  The  ilio-psoas  muscle 
arises  within  the  abdomen  and  passes  down  toward  Poupart's  liga- 
ment in  one  mass,  which  is  invested  by  a  strong  fascia,  the  iliac. 
At  Poupart's  ligament,  the  fascia  that  covers  the  outer  part  of  the 
psoas-iliacus — i.e.,  that  part  of  it  which  corresponds  to  the  outer 
third  of  Poupart's  ligament — is  attached  to  Poupart's  ligament,  and 
is  thence  reflected  upward,  becoming  continuous  with  the  transver- 
salis  fascia,  which  lines  the  whole  posterior  surface  of  the  anterior 
abdominal  wall.  Internal  to  this,  however,  where  the  femoral  ves- 
sels pass  out  under  Poupart's  ligament,  the  fascia  is  continued  down- 
ward with  the  muscle  underneath  Poupart's  ligament,  into  the 
thigh.  As  the  femoral  vessels  descend  into  the  thigh  they  rest  upon 
the  pectineus  and  ilio-psoas  muscles,  separated  from  them,  however, 
by  the  fascia  which  covers  them,  the  pectineal  fascia1  covering  the 
pectineus  muscle,  and  the  iliac  fascia  covering  the  ilio-psoas  muscle. 

The  fascia  iliaca,  immediately  beneath  Poupart's  ligament,  is 
thickened,  and  is  called  the  ilio-pectineal  ligament.  It  reaches  from 
the  junction  of  the  outer  and  middle  thirds  of  Poupart's  ligament  to 
the  ilio-pectineal  eminence,  and  serves  to  divide  the  space  under 
Poupart's  ligament  into  two  portions:  that  for  the  ilio-psoas  muscle 
and  anterior  crural  nerve,  below  and  externally,  and  that  through 
which  the  femoral  vessels  pass,  above  and  internally.  This  latter 
is  called  the  femoral  space.  The  boundaries  of  the-  femoral  space 
are,  above,  Poupart's  ligament;  below  and  externally,  the  ilio-pec- 
tineal ligament  (thickened  portion  of  the  iliac  fascia);  below  and 
internally,  the  pubic  ligament  of  Cooper  (the  upper  thickened  por- 
tion of  the  fascia  that  covers  the  pectineus  muscle);  internally,  the 
edge  of  Gimbernat's  ligament. 

As  the  femoral  vessels  pass  down  through  the  femoral  space 


1  That  part  of  the  pubic  portion  of  the  fascia  lata  that  covers  the  pectineus  muscle. 


OPERATIONS  FOR  HERNIA.  439 

into  the  thigh,  they  are  inclosed  in  a  connective  tissue  sheath,  which 
is  prolonged  downward  from  the  margins  of  this  space.  It  is  called 
the  femoral  sheath.  The  femoral  sheath  is  divided  into  three  com- 
partments by  septa:  the  outer  contains  the  artery;  the  middle  one, 
the  vein;  the  innermost,  that  between  the  vein  and  the  edge  of 
Gimbernat's  ligament,  is  the  so-called  crural  canal,  and  gives  pas- 
sage to  lymphatics  from  the  thigh  to  the  abdomen.  The  abdominal 
orifice  of  the  crural  canal  is  called  the  crural  ring. 

In  the  event  of  a  femoral  hernia,  a  process  of  peritoneum  (her- 
nial sac)  is  forced  into  the  crural  ring  and  down  through  the  crural 
canal,  appearing  below  in  the  upper  part  of  the  thigh  in  the  saphe- 
nous opening. 

The  coverings  of  a  femoral  hernia,  from  within  outward,  are, 
besides  its  peritoneal  sac,  the  femoral  sheath,  the  deep  layer  of  the 
superficial  fascia  (the  cribriform  fascia),  the  superficial  layer  of  the 
superficial  fascia  (fat),  and  the  skin. 

The  Obtukatok  Fokamen. — This  foramen  is  located  below  the 
brim  of  the  pelvis.  It  is  an  opening  in  the  upper  part  of  the  ob- 
turator membrane,  between  its  upper  edge  and  the  lower  border  of 
the  ramus  of  the  pubes.  This  foramen  gives  exit  to  the  obturator 
artery,  vein,  and  nerve,  and  is  sometimes  the  site  of  a  hernial  protru- 
sion. The  obturator  artery  usually  arises  from  the  external  iliac, 
passes  forward  just  below  the  brim  of  the  pelvis,  and  out  through 
the  obturator  foramen  into  the  thigh.  Occasionally,  however,  this 
artery  is  derived  from  the  deep  epigastric,  close  to  the  origin  of  this 
vessel  from  the  external  iliac  (femoral),  and  in  its  course  to  reach 
the  obturator  foramen  it  is  found  in  close  proximity  to  the  margin 
of  the  crural  ring.  After  its  origin  from  the  deep  epigastric,  in  its 
course  to  reach  the  obturator  foramen,  it  either  passes  around  the 
upper  and  inner  margins  of  the  crural  ring  or  else  it  descends  close 
to  the  inner  wall  of  the  femoral  vein  and  behind  the  outer  border  of 
the  crural  ring. 

OPERATIONS  FOR  HERNIA. 

Herniotomy.  —  Incision  of  the  coverings  of  a  hernia,  opening 
into  the  sac,  and  the  division  of  constricting  rings  or  bands  constitute 
the  operation  of  herniotomy.  The  operation  is  done  for  the  purpose 
of  liberating  a  strangulated  hernia.  The  constriction  may  be  caused 
by  bands  in  the  body  of  the  sac  or  by  the  neck  of  the  sac  itself,  but  in 


440 


HERNIA,  ETC. 


most  cases  it  is  probably  caused  by  the  firm,  unyielding  ring  by  which 
the  neck  of  the  sac  is  encircled. 

At  one  of  the  usual  sites  of  a  hernial  protrusion  there  is  found  a 
tense,  elastic  tumor.  The  incision  is  placed  over  the  most  prominent 
part  of  the  tumor,  cutting  carefully  through  the  skin  and  the  deeper 
layers  until  the  sac  proper  is  reached.  The  sac  may  then  be  pinched 
up  with  two  forceps  and  incised  between  them,  when  there  is  an 
escape  of  serous  fluid,  and  the  contents  of  the  sac  are  exposed. 


Fig.  188.— Irregular  Origin  of  Obturator  Artery.  In  its  course  into  the 
pelvis  it  lies  close  to  the  inner  side  of  the  femoral  vein.  A,  femoral  artery; 
E,  deep  epigastric  artery;  GL,  Gimbernat's  ligament;  IR,  internal  inguinal 
ring;  O,  obturator  artery;  PL,  Poupart's  ligament;  V,  femoral  vein.  The 
space  between  the  femoral  vein  and  Gimbernat's  ligament  is  known  as  the 
crural  ring,  and  through  this  femoral  hernia  leaves  the  abdomen. 


The  contents  vary;  they  may  consist  of  intestine,  large  or  small; 
of  omentum,  or  of  both;  and  occasionally  there  may  be  other  organs, 
such  as  the  bladder,  ovary,  etc.  After  the  sac  has  been  freely 
opened,  its  contents  should  be  examined.  Any  constricting  bands  in 
the  body  of  the  sac  should  be  divided,  and  an  attempt  then  made  to 
pull  the  gut  down  so  as  to  ease  it  at  the  point  of  constriction;  but 
in  this  effort  much  force  should  not  be  used.    An  effort  is  made  to 


OPERATIONS  FOR  HERNIA. 


441 


insert  the  finger  into  the  neck  of  the  sac,  and,  if  this  is  successful,  a 
probe-pointed,  curved  knife  may  be  introduced  upon  the  finger  and 
the  constricting  ring  incised.  If  one  is  unable  to  insert  the  finger 
into  the  neck  of  the  sac,  a  director  may  be  carried  through,  and  upon 
this  the  ring  may  be  divided.  In  freeing  the  constriction,  a  suc- 
cession of  nicks  should  be  made  rather  than  a  single  free  cut,  and 
these  may  be  repeated  until  the  parts  are  liberated. 

For  the  relief  of  an  indirect  inguinal  hernia  the  incision  in  the 


Fig.  1S9. — Irregular  Origin  of  Obturator  Artery.  In  its  course  into  the 
pelvis  it  curves  around  the  upper  and  inner  edge  of  the  crural  ring.  Letters 
same  as  18S. 


constricting  ring  should  be  directed  upward.  For  a  direct  inguinal 
hernia  the  incision  should  be  directed  upward  and  inward,  toward 
the  umbilicus.  For  a  femoral  hernia  the  incision  should  be  directed 
inward  toward  Gimbernat's  ligament  and  somewhat  upward. 

For  practical  purposes,  if  in  doubt  as  to  the  exact  variety  of  the 
hernia,  the  direction  of  the  liberating  incision  for  both  varieties  of 
inguinal  and  for  femoral  hernia  may  be  upward  and  inward,  toward 
the  umbilicus.     By  cutting  in  this  direction,  upward  and  inward, 


442  HERNIA,  ETC. 

toward  the  umbilicus,  we  work  in  a  line  which  is  parallel  with  the 
course  of  the  deep  epigastric  vessels,  and  the  danger  of  wounding 
these  is  thus  obviated. 

Occasionally  the  obturator  artery,  as  described  above,  is  given 
off  from  the  deep  epigastric,  and  in  its  course  to  reach  the  obturator 
foramen  this  vessel  would  then  have  a  close  relationship  to  the  neck 
of  the  sac  of  a  femoral  hernia.  From  its  origin,  at  the  deep  epigas- 
tric, the  obturator  artery  either  descends  close  to  the  inner  wall  of 
the  femoral  vein,  and  therefore  behind  the  outer  margin  of  the  crural 
ring,  and  would  thus  lie  to  the  outer  side  of  the  neck  of  a  femoral  her- 
nial sac,  or  else  it  curves  inward  and  then  downward,  behind  the  up- 
per and  inner  borders  of  the  crural  ring,  and  would  then  lie  above  and 
to  the  inner  side  of  a  femoral  hernial  sac.  In  the  first  case,  this  ves- 
sel would  be  out  of  the  way  in  making  the  liberating  incisions  at 
the  crural  ring,  whereas  in  the  second  instance  the  vessel  would  be 
jeoparded  in  making  the  liberating  incisions  if  caution  were  not  exer- 
cised. 

If  the  constriction  at  the  neck  of  the  sac  is  relieved  by  a 
succession  of  nicks,  rather  than  by  a  single  free  incision,  we  will 
be  very  much  less  liable  to  divide  an  abnormally  placed  obturator 
artery.  After  the  contents  of  the  sac  have  been  liberated  they  may 
be  drawn  down  for  examination,  especially  at  the  points  of  constric- 
tion. If  omentum  is  present,  this  may  be  ligated  and  amputated. 
As  to  the  treatment  of  the  gut,  careful  deliberation  must  be  used. 
If  the  gut  is  healthy,  it  may  be  returned  at  once  into  the  abdomen. 
If  doubtful,  one  may  wait  for  a  short  time  to  note  if  it  tends  to  clear 
up.  After  the  gut  has  been  reduced  the  finger  should  be  introduced 
through  the  neck  of  the  sac  in  order  to  make  certain  that  there  are 
no  adhesions  about  the  neck  which  might  continue  to  constrict  the 
gut. 

If  the  gut  is  gangrenous,  or  too  doubtful  to  return  into  the  ab- 
domen, the  incision  in  the  abdomen  at  the  neck  of  the  sac  should 
be  enlarged  and  the  gut  drawn  down  and  resected;  or  else  the  gut 
may  be  allowed  to  remain  without  disturbing  the  adhesions  about  the 
neck  of  the  sac,  and  an  artificial  anus  made  by  incising  the  strangu- 
lated coil  of  gut,  if  it  has  not  already  sloughed  through.  The  wound, 
under  these  circumstances,  should  be  left  open  and  packed. 

Radical  Operation  for  Inguinal  Hernia  (Bassini  Method).  For 
an  Oblique  Acquired  Hernia. — An  incision  is  made  through  the 
skin,  commencing  at  a  point  half  an  inch  above  and  somewhat  ex- 


OPERATIONS  FOR  HERNIA. 


443 


ternal  to  the  middle  of  Poupart's  ligament,  carrying  it  downward 
and  inward  as  far  as  the  spine  of  the  puhes;  or  it  may  he  prolonged 
for  a  short  distance  downward  upon  the  scrotum,  if  necessary.  This 
incision  penetrates  into  the  subcutaneous  fatty  layer.  In  its  upper 
part  the  incision  should  he  deepened  until  the  fibers  of  the  aponeu- 
rosis of  the  external  oblique  are  plainly  visible.  The  fingers  are 
then  introduced  into  this  upper,  deeper  part  of  the  incision,  and  it 


Y 


\ 

Fig.  190. — Operation  for  Inguinal  Hernia.  Incision  penetrates  through  the 
skin  and  fat,  exposing  the  aponeurosis  of  the  external  oblique.  SC,  spermatic 
cord  emerging  from  the  external  inguinal  ring. 

is  torn  open  down  to  its  lower  end.  After  this  has  been  done  the 
aponeurosis  of  the  external  oblique  and  the  pillars  of  the  external 
ring,  through  which  the  cord  emerges,  are  exposed. 

Any  bleeding  points  are  caught  in  artery  forceps;  but  it  is  not 
necessary  to  ligate  them  immediately,  as  the  hemorrhage  usually 
ceases  after  a  few  minutes'  compression. 

A  blunt  director  is  now  passed  into  the  external  ring,  and  car- 


444  HERNIA,  ETC. 

ried  upward  and  outward  beneath  the  aponeurosis  of  the  external 
oblique  to  a  point  beyond  the  middle  of  Poupart's  ligament,  the 
location  of  the  "internal  ring,"  and  upon  this  the  aponeurosis  is 
divided.  Some  obstruction  to  the  introduction  of  the  director 
through  the  external  ring  will  be  experienced  if  the  deep  layer  of  the 
superficial  fascia,  which  is  attached  to  the  margins  of  the  ring,  has 
not  been  incised. 

The  edges  of  the  split  aponeurosis  of  the  external  oblique  are 
seized  with  artery  forceps  and  separated  with  the  finger  from  the 
structures  which  lie  immediately  beneath.  The  inguinal  canal  is 
thus  laid  open,  and  the  spermatic  cord,  together  with  the  hernial 
sac,  is  exposed.  The  lower,  free  fleshy  edge  of  the  internal  oblique 
muscle  is  seen  arching  inward  over  the  cord  and  hernial  sac.  It  is 
blended  with  the  tendon  of  the  transversalis  muscle  to  form  the  con- 
joined tendon,  which  descends  behind  the  cord,  and  which  can  be  felt 
as  a  strong,  resistant  band  attached  to  the  crest  of  the  pubic  bone. 

The  spermatic  cord,  together  with  the  hernial  sac,  which  is 
usually  found  empty  unless  its  contents  are  irreducible  or  the  pa- 
tient is  straining,  is  now  hooked  up,  upon  the  finger,  and  we  proceed 
to  separate  the  sac  from  the  cord.  At  times  it  is  difficult  to  recog- 
nize the  sac.  It  is  formed  of  the  pouch  of  peritoneum,  with  some 
loose  connective  tissue  (subperitoneal  connective  tissue  layer)  and 
is  situated  within  the  proper  sheath  of  the  spermatic  cord  (infundib- 
ular process  of  transversalis  fascia),  which  must  be  incised  or  torn  in 
order  to  expose  it  (the  sac).  The  sac  has  a  peculiar,  white,  aponeurotic 
appearance,  and  may  be  very  thin  or  of  moderate  thickness.  The  isola- 
tion of  the  sac  from  the  cord  is  accomplished  chiefly  by  tearing  and 
separating  with  the  fingers,  occasionally  cutting  a  resisting  band  with 
the  scissors.  At  times  the  sac  is  very  intimately  united  with  the 
cord,  and  much  patience  is  required  to  separate  it.  One  should 
recognize  the  vas  deferens,  and  constantly  be  familiar  with  its  loca- 
tion, in  order  to  avoid  injuring  it.  In  isolating  the  sac,  one  may 
have  considerable  hemorrhage  from  the  pampiniform  plexus  of  veins, 
which  runs  along  with  the  vas  deferens,  etc.,  in  the  cord.  It  usually 
ceases,  however,  after  clamps  have  been  applied  to  the  bleeding 
points  for  a  few  minutes.  If  one  of  the  arterial  branches  which  run 
in  the  cord  is  torn,  it  will  be  necessary  to  apply  a  ligature.  One  may 
begin  the  separation  of  the  sac  from  the  cord  above  at  the  neck  of 
the  sac  and  work  downward,  toward  its  lower  part  (fundus),  or  com- 
mence at  the  fundus  and  work  upward,  toward  the  neck.     The  op- 


Fig.  191. — Bassini  Operation  for  Inguinal  Hernia.  The  inguinal  canal  laid  open  by  splitting 
the  aponeurosis  of  the  external  oblique.  The  edges  of  the  split  aponeurosis  seized  with  artery 
forceps  and  drawn  aside.  Spermatic  cord  retracted  with  a  loop  of  silk.  The  hernia  sac,  unopened, 
has  been  detached  from  the  spermatic  cord  and  reflected  upward  and  outward  ;  C.  T.,  edge  of 
conjoined  tendon  ;  P.,  edge  of  Poupart's  ligament;  T.F.,  trans versalis  fascia  which  forms  the 
posterior  wab  of  the  inguinal  canal. 


OPERATIONS  FOR  HERNIA.  445 

erator  may  assist  himself  in  separating  the  sac  from  the  cord  by  in- 
cising it  in  order  to  introduce  the  finger  into  it,  and  thus  inform 
himself  of  its  limits. 

After  the  sac  has  been  completely  separated  from  the  cord,  espe- 
cially above,  about  the  neck  at  the  location  of  the  "internal  ring,'' 
it  is  raised,  and  (if  not  already  incised)  is  seized  by  an  assistant  with 
the  fingers  of  both  hands,  or  with  two  artery  forceps,  and  incised 
between  them  with  the  knife.  In  incising  the  sac,  especially  if  the 
contents  are  adherent,  or  if  operating  upon  a  strangulated  hernia 
when  there  is  much  distension,  one  should  use  caution  not  to  wound 
the  parts  within.  After  the  sac  has  been  opened  the  contents  may 
be  reduced,  and,  if  there  are  no  adhesions,  this  is  very  readily  done. 
If  there  is  a  considerable  amount  of  prolapsed  omentum  in  the  sac, 
this  may  be  tied  off  with  stout  catgut  and  amputated  in  preference 
to  returning  it  to  the  abdomen.  If  the  contents  are  adherent  to  the 
sac,  they  must  be  gently  separated  before  they  can  be  reduced.  This 
can  usually  be  accomplished  with  the  finger,  taking  care  to  avoid 
tearing  the  gut,  and  ligating  any  points  that  bleed  freely.  Dense 
adhesion  bands  may  be  first  tied  double  and  then  divided  between 
the  ligatures.  If  omentum  is  adherent  within  the  sac,  it  may  be 
ligated  and  amputated.  The  contents-  should  be  free,  especially  at 
the  neck  of  the  sac,  in  order  that  they  may  be  properly  reduced. 

After  the  sac  has  been  emptied  we  may  tie  it  off.  The  finger  is 
introduced  into  the  sac  and  carried  well  within  its  mouth,  and  a  catgut 
ligature  (No.  2)  thrown  around  its  neck.  As  this  ligature  is  drawn 
tight  and  tied,  one  should  feel  it  slip  over  the  end  of  the  finger, 
which  is  within  the  mouth  of  the  sac.  It  should  be  applied  about 
the  neck  of  the  sac  as  high  up  as  possible,  in  order  to  avoid  leaving 
any  pouched  portion  of  the  sac  to  invite  the  recurrence  of  the  her- 
nia. The  ligature  is  left  long  for  use  as  a  tractor,  and  the  sac  is  cut 
away,  about  one-fourth  inch  distal  from  the  ligature.  Then,  after 
a  final  examination  of  the  stump  of  the  sac,  the  ends  of  the  ligature 
are  cut  short,  and  the  stump  of  the  sac  allowed  to  retract  into  the 
abdomen.  If  the  sac  is  rather  wide-mouthed,  instead  of  simply 
surrounding  it  with  a  ligature  one  may  transfix  it  with  a  ligature 
carried  in  a  curved  needle  and  tie  double. 

The  next  step  in  the  operation  is  the  strengthening  of  the  poste- 
rior wall  of  the  inguinal  canal,  and  this  is  done  by  approximating 
the  free  edge  of  the  internal  oblique  and  transversalis  muscles  (con- 
joined tendon)  above  to  Poupart's  ligament  below.     While  this  is 


446  HERNIA,  ETC. 

being  done  the  spermatic  cord  is  held  out  of  the  way  of  the  operator 
upon  a  strip  of  gauze,  and  the  upper  edge  of  the  divided  aponeurosis 
of  the  external  oblique,  which  is  held  in  an  artery  forceps,  is  re- 
tracted, in  order  that  the  edge  of  the  internal  oblique  and  trans- 
versalis  (conjoined  tendon)  may  be  made  out.  These  parts  can  be 
readily  seen  and  may  be  plainly  felt  by  the  finger  in  the  wound. 
Poupart's  ligament  is  likewise  freely  exposed,  when  the  lower  edge 
of  the  aponeurosis  of  the  external  oblique  is  strongly  retracted.  This 
structure  may  be  recognized  as  a  sharp,  white  band.  These  parts, 
the  conjoined  tendon  above  and  Poupart's  ligament  below,  are  now 
brought  together  with  three  to  five  interrupted  sutures  of  some  per- 
manent material,  such  as  silk-worm  gut,  silk,  silver  wire,  kangaroo 
tendon,  or  chromicized  gut.  These  sutures  are  introduced  with  a 
large,  curved  needle  grasped  in  a  needle  holder.  The  first  suture  is 
placed  externally,  just  to  the  inner  side  of  where  the  cord  emerges 
from  the  abdomen;  the  last  one  or  two  sutures,  those  nearest  the 
middle  line,  should  take  a  sufficiently  broad  bite  to  include,  together 
with  the  conjoined  tendon,  the  edge  of  the  rectus  muscle.  Each 
suture  should  take  a  good,  broad  bite.  In  introducing  the  sutures 
through  Poupart's  ligament  there  is  said  to  be  some  danger,  espe- 
cially with  the  middle  sutures,  of  piercing  the  femoral  vein  with 
the  needle.  This  might  happen  if  the  needle  were  inserted  too 
deeply,  but  this  is  not  necessary,  as  a  good,  broad  bite  of  the  liga- 
ment is  easily  secured  without  introducing  the  needle  deep  enough 
to  reach  the  vein.  The  sutures  are  left  long,  and  are  not  tied  until 
all  are  introduced.  Usually  three  or  four  sutures  suffice;  sometimes 
five  are  necessary.  The  most  external  suture  should  be  placed  so  as 
to  leave  just  space  enough  for  the  cord  to  emerge  comfortably  with- 
out constriction  between  the  edge  of  the  internal  oblique  and  trans- 
versalis  above  and  Poupart's  ligament  below.  When  the  sutures  are 
tied,  the  edge  of  the  internal  oblique  and  transversalis  muscles  (con- 
joined tendon)  and  Poupart's  ligament  are  seen  to  be  closely  ap- 
proximated, and  in  this  way  there  is  formed  a  solid  posterior  wall 
to  the  inguinal  canal,  upon  which  the  cord  rests  when  it  is  dropped 
back  into  the  wound.  The  edges  of  the  split  aponeurosis  of  the 
external  oblique  are  now  brought  together  over  the  cord  with  a  con- 
tinuous suture  of  catgut,  simple  or  chromicized,  No.  2.  This  suture 
is  commenced  above  and  externally,  and  terminates  below  at  the  site 
of  the  former  external  abdominal  ring.  In  this  way  the  anterior  wall 
of  the  inguinal  canal  is  restored,  and  beneath  this  the  cord  is  situ- 


Fig.  192. — The  Bassini  Operation.  The  edges  of  the  split  aponeurosis  held 
aside  with  artery  forceps.  Conjoined  tendon  sutured  to  the  edge  of  Poupart's. 
Spermatic  cord  (CIS.)  drawn  aside  with  a  tractor. 


OPERATIONS  FOR  HERNIA.  447 

ated.  One  should  take  care  that  the  cord  is  not  gripped  too  tightly 
between  the  posterior  and  anterior  walls  of  the  new  canal,  and  that, 
at  the  site  of  the  external  ring,  sufficient  space  is  left  for  the  cord 
to  emerge  without  danger  of  its  becoming  strangulated. 

The  wound  should  be  dry — free  from  oozing.  No  drainage  is 
necessary.  The  incision  in  the  skin  may  be  closed  with  a  continuous 
intracuticular  catgut  suture. 

In  the  female  this  operation  is  simplified  in  that  we  have  no 
spermatic  cord  to  consider;  the  round  ligament,  its  analogue,-  is  sim- 
ply cut  away,  and  the  deep  sutures  which  strengthen  the  posterior 
wall  of  the  inguinal  canal  introduced  in  the  manner  described  above. 

For  a  Congenital  Hernia. — In  this  variety  of  hernia  the  sac 
is  formed  of  the  unobliterated  vaginal  process  of  the  peritoneum,  at 
the  bottom  of  which  the  testis  usually  lies.  In  some  cases  the.  testis 
does  not  reach  the  bottom  of  the  scrotum  in  its  descent,  and  may 
remain  stationary,  in  any  part  of  the  inguinal  canal  or  within  the 
abdomen,  when  it  may  be  wise  to  remove  it.  The  incision  in  the 
skin  and  aponeurosis  of  the  external  oblique  are  made  as  in  the  fore- 
going operation.  After  the  inguinal  canal  has  been  laid  open,  the 
cord,  together  with  the  sac,  is  picked  up,  upon  the  finger.  The  her- 
nial sac  is  really  included  within  the  proper  sheath  of  the  cord,  in- 
fundibular process,  and  its  isolation  from  the  elements  of  the  cord 
may  be  somewhat  difficult.  The  sheath  of  the  cord  (infundibular 
process  of  the  transversalis  fascia)  must  be  incised  or  torn  through 
in  order  to  reach  the  sac.  In  separating  the  sac  we  may  commence 
above  at  the  neck  of  the  sac,  and  work  downward,  toward  the  testis. 
After  the  sac  has  been  separated  from  the  cord,  vas  deferens,  etc.,  to 
a  point  which  is  just  above  the  testis,  it  is  opened  and  its  contents 
reduced.  The  sac  is  then  cut  across,  allowing  the  lower  part,  that 
which  corresponds  to  the  testis,  to  remain  to  form  the  tunica  vag- 
inalis. The  upper  part  of  the  sac,  after  having  been  thoroughly  iso- 
lated, is  then  tied  off  at  the  point  where  it  emerges  from  the  abdo- 
men, and  the  edge  of  the  internal  oblique  and  transversalis  (con- 
joined tendon)  sutured  to  Poupart's  ligament,  as  already  described 
in  the  preceding  operation.  The  lower  part  of  the  vaginal  process 
(hernial  sac)  which  remains,  and  which  corresponds  to  the  tunica 
vaginalis  testis,  is  then  closed  with  a  continuous  catgut  suture,  so 
that  the  testis  is  shut  up  within  its  tunica  vaginalis.  The  edges  of 
the  split  aponeurosis  of  the  external  oblique  are  then  brought  to- 
gether over  the  cord,  and  the  incision  in  the  skin  closed.     If  the 


44S  HERNIA,  ETC. 

testis  has  been  much  handled,  it  may  be  wise  to  introduce  a  thin 
strip  of  gauze  into  the  cavity  of  the  tunica  vaginalis,  through  the 
bottom  of  the  scrotum,  for  the  purpose  of  drainage;  usually,  how- 
ever, this  is  not  necessary. 

Foe  a  Direct  Inguinal  Hernia. — In  this  variety  of  hernia  the 
peritoneal  pouch  (hernial  sac)  does  not  enter  the  "internal  ring," 
mouth  of  the  infundibular  process,  and  work  its  way  down  along  the 
cord,  within  the  sheath  of  the  cord,  but  bulges  directly  forward,  into 
the  inguinal  canal,  to  the  inner  side  of  the  deep  epigastric  artery, 
pushing  the  transversalis  fascia,  conjoined  tendon,  and  triangular 
ligament  before  it,  and  is  found  upon  the  inner  side  of  the  spermatic 
cord  as  this  descends  through  the  inguinal  canal.  The  sac  consists 
of  a  wide-mouthed  pouch  of  peritoneum  and  subperitoneal  connect- 
ive tissue,  and,  as  it  presents  into  the  inguinal  canal,  is  covered 
by  the  transversalis  fascia,  the  conjoined  tendon,  and  the  triangular 
ligament.  It  is  also  covered  by  the  aponeurosis  of  the  external 
oblique,  superficial  and  deep  layers  of  the  superficial  fascia,  and  the 
skin.  The  mouth  of  the  sac  is  wide,  and  may  reach  from  the  external 
edge  of  the  rectus  as  far  outward  as  the  deep  epigastric  artery,  or 
even  beyond  this,  pushing  the  artery  in  front  of  it,  in  which  case 
the  artery  may  form  a  deep  groove  upon  the  sac,  and  thus  divide  H 
into  two  pouches.  Under  these  circumstances  it  may  be  necessary  to 
tie  the  artery  double  and  divide  it.  There  may  be  no  well-formed 
sac  present,  but  simply  a  wide,  conical  bulging  of  the  posterior  wall 
of  the  inguinal  canal.  In  direct  hernia  the  sac  is  readily  separated 
from  the  cord,  after  which  it  is  opened  and  its  contents  reduced.  If 
the  sac  is  very  wide-mouthed,  it  may  be  necessary  to  approximate  the 
margins  of  the  opening  with  a  catgut  suture,  and  then  cut  away  what 
remains  of  the  sac.  The  operation  is  completed  as  described  above  for 
the  oblique  variety.  While  the  cord  is  held  aside,  the  edge  of  the  con- 
joined tendon  (internal  oblique  and  transversalis  muscles)  is  sutured  to 
Poupart's  ligament.  The  cord  is  then  replaced  and  the  edges  of  the 
aponeurosis  of  the  external  oblique  sutured  over  it,  and  finally  the 
incision  in  the  skin  closed. 

Halsted's  Operation  for  Inguinal  Hernia. — The  incision  reaches 
from  a  point  5  cm.  above  and  external  to  the  site  of  the  internal 
ring,  which  is  located  half  an  inch  above  the  middle  of  Poupart's 
ligament.  It  is  carried  downward  and  inward  as  far  as  the  spine  of 
the  pubes  (site  of  the  external  ring).  This  incision  extends  through 
the  skin  and  superficial  fascia,  freely  exposing  the  aponeurosis  of 


OPERATIONS  FOR  HERNIA.  449 

the  external  oblique  muscle  and  the  external  inguinal  ring.  All 
bleeding  points  are  clamped.  As  a  rule,  it  is  not  necessary  to  tie 
them,  as  the  hemorrhage  ceases  after  a  few  minutes'  compression. 

The  next  step  in  the  operation  consists  in  the  division  of  the 
aponeurosis  of  the  external  oblique,  the  internal  oblique  and  trans- 
versalis  muscles,  and  the  transversalis  fascia.  These  structures  are 
incised  from  the  external  ring  below  to  a  point  about  2  cm.  above 
and  external  to  the  location  of  the  internal  ring,  or  farther  if  neces- 
sary, in  order  that  the  upper  and  outer  part  of  the  incision  may  ex- 
tend into  the  fleshy  part  of  the  internal  oblique  and  transversalis 
muscles.  The  vas  deferens  is  now  sought,  and,  together  with  its 
vessels,  isolated,  and  then  all  the  veins  which  accompany  the  vas 
deferens  except  two  or  three,  after  being  tied  off  above  and  below, 
are  excised.  In  this  way  the  size  of  the  cord  is  markedly  dimin- 
ished. The  remains  of  the  cord  are  now  held  to  one  side,  and  the 
isolation  of  the  hernial  sac  is  begun.  After  this  has  been  completed, 
the  sac  is  incised  and  its  contents  returned  into  the  abdomen.  When 
the  transversalis  fascia  is  incised  the  constriction  about  the  neck  of 
the  sac  disappears,  and  its  mouth,  from  a  narrow  orifice,  becomes  a 
wide-open  space,  through  which  one  may  easily  introduce  several 
fingers  or  the  whole  hand  into  the  peritoneal  cavity.  The  margins 
of  the  mouth  of  the  sac  are  now  brought  together  with  a  continuous 
or  interrupted  suture  of  catgut,  and  the  sac  below  this  suture  line 
resected.  This  step  of  the  operation  is  really  like  closing  any  ordi- 
nary opening  in  the  parietal  peritoneum.  During  the  application  of 
this  suture  a  gauze  pad  may  be  introduced,  through  the  opening  into 
the  peritoneal  cavity,  to  prevent  the  intestine  from  prolapsing  into 
the  wound.  After  the  mouth  of  the  sac,  peritoneum,  has  been  thus 
sutured  and  closed,  and  the  sac  cut  away,  we  proceed  with  the  next 
step  of  the  operation,  the  approximation  of  the  cut  edges  of  the 
several  layers  of  the  abdominal  wall.  While  this  is  being  accom- 
plished the  cord  is  raised  upon  a  hook  and  held  out  of  the  way,-  well 
toward  the  outer  part  of  the  incision.  To  unite  these  parts  from  six 
to  eight  mattress  sutures  of  silk  are  required.  The  layers  which  are 
approximated  consist  above  of  the  aponeurosis  of  the  external 
oblique,  the  internal  oblique  and  the  transversalis  muscles  (con- 
joined tendon),  and  the  transversalis  fascia.  Below  they  consist  of 
Poupart's  ligament  and  the  aponeurosis  of  the  external  oblique  and 
the  transversalis  fascia,  and  in  part,  externally,  of  the  cut  edges  of 
the  internal  oblique  and  transversalis  muscles.     The  sutures  pass 


450 


HERNIA,  ETC. 


through  all  these  layers.  Between  the  two  most  external  of  these 
sutures  the  cord  emerges  through  the  abdominal  wall,  between  the  cut 
edges  of  the  internal  oblique  and  transversalis  muscles.  The  cord 
should  be  firmly  grasped  by  these  muscles,  but  not  tightly  enough 


Fig.  193.— Halsted's  Operation.  The  vas  deferens,  with  a  few  remaining 
vessels  of  the  cord,  drawn  aside  with  a  hook.  Mattress  sutures  have  been 
applied,  uniting  the  different  layers  that  have  been  cut,  including  the  apo- 
neurosis of  the  external  oblique. 


to  strangle  it.  The  cord,  as  it  emerges  through  the  abdominal  wall, 
in  its  new  position,  should  be  surrounded  by  the  fleshy  fibers  of  these 
muscles;  it  should  not  emerge  between  the  tendinous  portions  of 
the  muscles.    If  the  incision  through  the  internal  oblique  and  trans- 


OPERATIONS  FOR  HERNIA.  451 

versalis  muscles  and  the  transversalis  fascia  has  not  been  carried 
sufficiently  far,  in  a  direction  upward  and  outward,  to  accomplish 
this,  it  should  be  extended  farther,  so  as  to  reach  well  into  the  fleshy 
portion  of  these  muscles. 

After  the  mattress  sutures  have  been  applied  and  the  parts  al- 
ready mentioned  approximated,  the  cord  is  dropped  back  into  the 
wound  and  rests  upon  the  aponeurosis  of  the  external  oblique.  The 
edges  of  the  skin  are  then  sutured  over  the  cord  with  a  continuous 
intracuticular  suture,  thus  completing  the  operation.  The  cord  is 
transplanted  so  that  it  emerges  through  the  abdominal  wall  above 
and  external  to  the  site  of  the  "internal  ring,'>  where  it  is  surrounded 
by  muscular  fibers  and  lies  just  beneath  the  skin,  instead  of  beneath 
the  aponeurosis  of  the  external  oblique. 

Operation  for  the  Radical  Cure  of  Femoral  Hernia.  —  Femoral 
hernia  descends  through  the  crural  canal  upon  the  inner  side  of  the 
femoral  vein,  and  presents  in  the  thigh,  just  below  Poupart's  liga- 
ment. In  order  to  expose  the  sac  of  the  hernia  an  incision  is  made 
below  and  parallel  with  Poupart's  ligament,  the  middle  of  the  in- 
cision being  over  the  center  of  the  tumor.  This  incision  is  carried 
through  the  skin  and  subcutaneous  fatty  tissue  and  the  deep  layer 
of  the  superficial  fascia  (cribriform)  down  to  the  sac.  Instead  of 
being  placed  parallel  with  Poupart's  ligament,  the  incision  may  be 
made  in  an  oblique  direction  from  above  downward. 

The  sac  is  now  isolated,  and  separated  from  the  adjoining  parts 
up  to  and  beyond  the  level  of  Poupart's  ligament.  Special  care  is 
required  in  separating  the  sac  on  the  side  which  adjoins  the  femoral 
vein.  After  the  sac  has  been  thoroughly  isolated  it  is  opened  and 
the  contents  reduced.  The  sac  is  then  twisted  and  tied  off  as  high  up 
as  possible.  It  may  be  surrounded  with  a  simple  catgut  ligature,  or 
it  may  be  transfixed  and  tied  double.  The  portion  of  the  sac  below 
the  ligature  is  then  cut  away,  the  ends  of  the  ligature  cut  short,  and 
the  stump  of  the  sac  pushed  back  beyond  Poupart's  ligament  into 
the  abdomen. 

We  are  now  ready  to  close  the  orifice  through  which  the  hernia 
descended  into  the  thigh.  We  should  first  recognize  the  margins  of 
this  orifice,  the  crural  ring.  This  is  bounded  above  by  Poupart's 
ligament;  internally  by  the  edge  of  Gimbernat's  ligament;  below 
by  the  fascia  that  covers  the  pectineus  muscle,  the  upper,  thickened 
portion  of  which  is  called  the  pubic  ligament  of  Cooper,  and  which  ex- 
tends from  Gimbernat's  ligament  to  the  pectineal  eminence;  externally 


452  HERNIA,  ETC. 

it  is  bounded  by  the  femoral  vein.  The  edge  of  the  falciform  process 
should  also  be  recognized,  and  likewise  the  internal  saphenous  vein, 
where  it  joins  the  femoral.  The  crural  ring  is  obliterated  by  sutur- 
ing the  lower  edge  of  Poupart's  ligament  to  the  fascia  which  covers 
the  pectineus  muscle;  i.e.,  to  that  part  of  it  which  covers  the  upper 
part  of  the  pectineus— the  pubic  ligament  of  Cooper.  The  stitches 
should  be  of  silk,  and  should  be  introduced  with  a  short,  full-curved 
needle.  The  first  suture  catches  Poupart's  ligament  just  external  to 
its  attachment  to  the  pubic  spine,  and  should  take  a  good  bite.  After 
the  needle  is  drawn  through  Poupart's  ligament  is  pulled  upward  and 
backward  with  a  blunt  hook  in  order  to  permit  the  needle  to  catch 
the  pectineal  fascia  as  high  up  under  Poupart's  ligament  as  pos- 
sible; i.e.,  near  the  ilio-pectineal  line,  from  which  the  pectineus  mus- 
cle arises.  Half  a  centimeter  external  to  this  suture  a  second  suture 
is  introduced  in  a  similar  manner,  and  then,  at  a  distance  of  another 
half-centimeter,  a  third  suture.  These  three  sutures  suffice  to  close 
the  opening.  The  third  and  last  suture  is  located  about  1  cm.  to  the 
inner  side  of  the  femoral  vein.  When  these  sutures  are  tied,  the 
lower  edge  of  Poupart's  ligament  and  the  pectineal  fascia  (the  thick- 
ened portion,  high  up  near  the  origin  of  the  pectineus  muscle  from 
the  ilio-pectineal  line)  are  approximated,  and  the  crural  ring  is  thus 
obliterated.  The  opening  in  the  skin  is  closed  in  the  usual  way.  No 
drainage  is  required. 

For  Undescended  Testicle  (Bevan's  Operation). — The  undescended 
testicle  may  be  found  within  the  abdomen  at  the  internal  ring;  in 
the  inguinal  canal ;  or  external  to  the  inguinal  canal,  underneath  the 
skin.  In  connection  with  this  condition  there  is  almost  always  asso- 
ciated a  patent  vaginal  process  and  therefore  a  condition  of  congenital 
hernia  either  actual  or  latent.  Bevan  advises  that  the  time  to  operate 
is  between  the  ages  of  six  and  twelve  years. 

An  incision  three  inches  long  is  made  from  a  point  half  an  inch 
above  the  middle  of  Poupart's  ligament  to  the  base  of  the  scrotum. 
The  incision  divides  the  integument  and  the  aponeurosis  of  the  ex- 
ternal oblique.  The  edges  of  the  aponeurosis  are  seized  with  artery 
forceps  and  well  retracted,  thus  exposing  the  cremasteric  fascia,  which 
fills  in  the  space  between  the  lower  edge  of  the  internal  oblique  muscle 
(conjoined  tendon)  and  Poupart's  ligament  (see  Fig.  195).  This 
layer  of  fascia  is  incised  together  with  the  underlying  fascia  transver- 
salis,  and  there  is  then  exposed  to  view  the  peritoneal  pouch  or  sac 
within  which  the  testis  is  situated.    When  this  peritoneal  pouch  or  sac 


Fig.  194.— Operation  for  Femoral  Hernia.  FY,  femoral  vein.  Poupart's 
ligament  has  been  sutured  to  the  upper  part  of  the  fascia  that  covers  the 
pectineus  muscle. 


OPERATIONS  FOR  HERNIA.  453 

is  incised  the  testicle  is  exposed  and  the  operator  finds  himself  within 
the  vaginal  process  (tunica  vaginalis),  which  is  found,  as  a  rule,  to 
communicate  direct  with  the  peritoneal  cavity  (see  Fig.  196). 

The  vaginal  process  of  peritoneum  (the  peritoneal  pouch  con- 
taining the  testicle)  is  now  divided  just  above  the  testicle  and  the 
upper  portion  of  it  peeled  upward  away  from  the  structures  that  go 
to  make  up  the  spermatic  cord  and  which  lie  beneath  it;  it  is  then 
transfixed  with  the  needle  and  tied  high  up  with  a  catgut  ligature. 
This  portion  of  the  sac  should  be  tied  upon  the  point  of  the  finger 
placed  within  it,  just  as  in  tying  off  an  ordinary  hernia  sac  so  as  not 
to  include  a  process  of  gut  or  omentum  which  might  have  entered  it. 
A  purse-string  suture  is  applied  around  the  edge  of  the  remaining, 
lower,  portion  of  the  vaginal  process,  the  portion  corresponding  to  the 
testis,  drawn  tight  and  tied ;  the  testis  is  thus  inclosed  in  that  portion 
of  the  vaginal  process  which  corresponds  to  the  normal  tunica  vaginalis 
(see  Fig.  197). 

The  testicle  is  now  lifted  out  of  its  bed  and  traction  made  upon 
the  cord  in  order  to  lengthen  it  as  much  as  possible.  Tense,  short 
bands  of  connective  tissue  that  bind  the  cord  and  prevent  its  being 
pulled  down  should  be  torn  across  with  thumb  forceps.  The  cord  is 
thus  stripped  of  all  the  surrounding  fascia  and  connective  tissue, 
leaving  nothing  but  the  vessels  of  the  cord  and  the  vas  deferens.  This 
part  of  the  operation  should  be  done  carefully  and  without  too  much 
precipitation. 

The  spermatic  vessels  and  vas  deferens,  which  are  situated  behind 
the  posterior  layer  of  the  peritoneum,  within  the  abdominal  cavity, 
should  be  separated  by  careful  blunt  dissection  with  the  finger  within 
the  abdomen.  The  spermatic  vessels  take  a  direction  upward  and 
inward  and  the  vas  downward  and  inward,  and  this  divergence  can  be 
distinctly  appreciated.  The  cord  should  be  sufficiently  lengthened  by 
these  manipulations  as  to  permit  of  the  testicle  being  drawn  down 
upon  the  thigh,  three  or  four  inches  below  Poupart's  ligament  (see 
Fig.  198). 

A  larger  pocket  is  now  torn  in  the  scrotum  with  the  finger  and 
into  this,  enclosed  in  its  newly  made  tunica  vaginalis,  the  testicle  is 
dropped,  and  here  it  should  remain  without  undue  tension  on  the 
cord.  A  purse-string  suture  is  applied  to  the  neck  of  the  pouch  in 
which  the  testicle  has  been  placed  so  as  to  hold  it  there;  this  suture, 
which  is  of  chromicized  catgut,  includes  the  superficial  fascia,  and  both 
edges  of  the  split  aponeurosis  of  the  external  oblique,  and  when  tied 
retains  the  testis  securely  in  its  new  scrotal  pocket. 


454 


HERNIA,  ETC. 


Fig.  195. — For  Undescended  Testis.      Aponeurosis  of  external  oblique  has  been 
.    split  and  reflected,  exposing  the  cremasteric  fascia. 


***?£££»■ 


V**LvW- 


Fig.   196.— For  Undescended  Testis.     Vaginal  process  incised   and  testicle 
exposed. 


OPERATIONS  FOR  HERNIA. 


455 


^iCtuJU*    to  toVHt. 


Fig.  197. — For  Undescended  Testis.  Purse-string  suture  applied  around 
the  edge  of  that  portion  of  the  vaginal  process  which  corresponds  to  the 
tunica  vaginalis. 


Fig.  198.— For  Undescended  Testis.  Upper  portion  of  vaginal  process  tied 
off.  Lower  portion  encloses  testicles.  Testicle  has  been  freed  and  drawn 
down  preparatory  to  placing  it  in  scrotum. 


456  HERNIA,  ETC. 

The  incision  is  closed  by  suturing  the  conjoined  tendon  to  Pou- 
part's  ligament,  over  the  cord,  thus  burying  the  cord  beneath  them, 
with  a  sufficient  number  of  interrupted  sutures  of  chromicized  catgut. 
The  edges  of  the  aponeurosis  of  the  external  oblique  are  then  approxi- 
mated with  a  continuous  suture  of  catgut  and  the  skin  incision  finally 
closed. 

In  some  few  cases  where  the  testis  is  situated  within  the  abdomen 
it  may  be  necessary  to  sever  the  spermatic  vessels  before  the  testis 
can  be  brought  down.  These  vessels  run  an  almost  straight  course 
from  and  to  the  aorta  and  vena  cava,  etc.,  and  on  account  of  their 
relative  shortness  they  may  fix  the  testis  so  that  it  cannot  be  pulled 
down  sufficiently.  The  vessels  should  be  ligated  doubly  and  divided 
between  the  ligatures.  The  testis  may  then  be  more  readily  drawn 
down  toward  the  scrotum.  The  division  of  the  spermatic  vessels  does 
not  interfere  seriously  with  the  nutrition  of  the  testis,  because  suffi- 
cient blood-supply  is  still  provided  through  the  artery  of  the  vas 
deferens,  which  anastomosis  freely  with  the  terminal  branches  of  the 
spermatic  that  are  destined  for  the  supply  of  the  testis.  Special  care 
must  be  exercised  not  to  injure  the  artery  and  veins  of  the  vas  deferens 
nor  to  include  them  in  the  ligatures  with  which  the  spermatic  vessels 
are  secured,  so  that  the  testis  will  not  be  deprived  of  its  entire  blood- 
supply  (see  "Spermatic  Cord"  and  "Varicocele"). 

THE  SPERMATIC  CORD,  SCROTUM,  ETC. 

The  Spermatic  Cord. — The  spermatic  cord  descends  through  the 
inguinal  canal,  emerging  at  the  external  inguinal  ring.  As  it  emerges 
from  the  external  ring  it  lies  just  beneath  the  integument  in  the  sub- 
cutaneous fat,  and  descends  into  the  scrotum,  where  it  is  joined  to 
the  posterior  border  of  the  testis.  It  is  about  as  thick  around  as  the 
little  finger,  and  is  made  up  of  a  bundle  of  structures,  the  vas  deferens, 
the  artery  of  the  vas  deferens,  and  the  cremasteric  artery,  their  corre- 
sponding veins,  the  spermatic  artery,  and  a  tortuous  venous  plexus, 
the  pampiniform.  The  vas  deferens,  the  efferent  duct  of  the  testis, 
occupies  the  posterior  part  of  the  cord.  The  vas  deferens  is  about 
as  big  around  as  a  goose  quill,  has  a  firm  feel,  and  may  be  readily 
recognized  as  it  is  rolled  between  the  fingers.  The  artery  of  the  vas 
deferens  ramifies  upon  the  vas  deferens,  supplies  it,  and  anastomoses 
below  with  the  spermatic  artery.  The  cremasteric  artery  is  distributed 
to  the  constituents  of  the  cord,  and  supplies  its  sheath.    The  spermatic 


THE  SPERMATIC  CORD,  SCROTUM,  ETC.  457 

artery  is  given  off  from  the  aorta;  it  supplies  the  testis  and  has  a 
strong  current  of  blood.  The  pampiniform  plexus  is  a  tortuous,  in- 
tercommunicating plexus  of  venous  channels  that  accompanies  the 
other  elements  of  the  cord.  Through  this  plexus  the  blood  is  returned 
from  the  testis.  The  vessels  of  the  pampiniform  plexus  join  together 
above  to  form  the  spermatic  vein.  This  vein  upon  the  right  side 
enters  the  vena  cava  directly;  upon  the  left  side  it  empties  into  the 
renal  vein,  so  that  the  venous  return  on  the  left  side  is  less  direct 
than  upon  the  right  side.  Varicocele  is  usually  found  upon  the  left 
side. 

As  these  structures  traverse  the  inguinal  canal  they  are  all  con- 
tained within  the  infundibular  process,  which  serves  to  bind  them 
together  into  a  single  bundle  and  which  forms  the  real  fibrous  sheath 
of  the  cord,  the  fascia  propria.  Descending  upon  the  cord  is  a  series 
of  looped,  muscular  fibers,  each  joined  to  the  other  by  an  intervening 
thin  fascia.  These  are  the  cremaster  muscle  and  fascia.  These  fibers, 
that  form  the  cremaster  muscle,  are  derived  from  the  lower  border  of 
the  internal  oblique. 

As  the  cord  emerges  from  the  external  inguinal  ring,  the  deep 
layer  of  the  superficial  fascia  (spermatic  fascia),  which  is  attached  to 
the  pillars  or  margins  of  the  ring,  is  continued  down  upon  the  cord, 
inclosing  it  and  forming  one  of  its  investments. 

The  Scrotum. — The  scrotum  is  a  tegumentary  pouch  which  is 
made  up  of  two  compartments,  one  on  each  side,  separated  by  a  median 
septum.  It  consists  of  several  layers  from  without  inward.  The 
skin  is  redundant,  corrugated,  and  wrinkled.  Beneath  the  skin 
is  the  dartos.  The  dartos  is  a  loose,  reddish,  contractile  layer, 
which  is  found  immediately  beneath  the  skin.  It  contains  some  mus- 
cular fibers,  and  is  continuous  behind  with  the  two  layers  of  the  super- 
ficial perineal  fascia,  and  laterally  with  the  same  layers  in  the  groin. 
It  sends  a  septum  into  the  scrotum,  which  divides  it  into  its  two 
halves.  Beneath  the  dartos  is  the  cremaster  muscle  and  fascia,  and 
beneath  this  the  infundibular  fascia,  and,  finally,  most  internal,  the 
parietal  layer  of  the  tunica  vaginalis. 

The  Testes. — The  testes  are  situated  in  the  scrotum,  each  sus- 
pended by  its  spermatic  cord.  They  are  partially  invested  by  a  closed, 
serous  sac,  the  tunica  vaginalis.  This  is  the  unobliterated  part  of  the 
vaginal  process  of  the  peritoneum,  the  peritoneal  pouch  that  accom- 
panies the  testis  in  its  descent  from  the  abdomen  into  the  infundibular 
process,  the  scrotum,  before  birth. 


458  HERNIA,  ETC. 

If  we  cut  through  the  anterior  wall  of  the  scrotum,  through 
these  various  layers,  we  enter  the  cavity  of  the  tunica  vaginalis,  which 
contains  normally  a  small  quantity  of  serous  fluid.  The  testis  pre- 
sents into  this  cavity,  being  partially  invested  by  the  visceral  layer 
of  the  tunica  vaginalis.  The  posterior  border  of  the  testis  is  not 
covered  by  the  tunica  vaginalis,  and  is  excluded  from  the  cavity  of 
the  tunica  vaginalis. 

Along  the  posterior  border  of  the  testis  is  the  epididymis.  It 
surmounts  the  testis  above  like  a  cap.  It  has  a  body,  an  upper,  larger 
portion,  the  globus  major;  and  a  lower,  smaller  portion,  the  globus 
minor.  The  vas  deferens  is  the  continuation  of  the  epididymis.  It 
commences  at  the  lower  end  of  the  globus  minor,  and,  passing  upward 
along  the  posterior,  inner  border  of  the  testis,  is  found  in  the  pos- 
terior part  of  the  spermatic  cord,  passing  through  the  "internal  ring" 
into  the  abdomen.  Within  the  abdomen  it  dips  down  into  the  pelvis, 
to  terminate  between  the  base  of  the  bladder  and  the  rectum,  where 
it  joins  with  the  duct  of  the  seminal  vesicle  of  the  corresponding  side 
to  form  the  ejaculatory  duct. 

The  Ejaculatory  Ducts. — The  ejaculatory  ducts  are  two  in  num- 
ber, one  on  each  side.  They  are  about  three-fourths  inch  long,  pass 
forward  through  the  prostate  gland,  one  on  either  side  of  the  middle 
line,  between  the  middle  and  lateral  lobes  of  the  prostate,  and  open 
upon  the  floor  of  the  prostatic  urethra. 

OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC. 

For  Varicocele.  Open  Operation. — An  incision  is  made,  about 
one  and  one-half  inches  long,  into  the  upper  part  of  the  front  of  the 
scrotum,  commencing  just  below  the  spine  of  the  pubes,  and  passing 
through  the  skin  into  the  subcutaneous  fatty  layer.  This  incision 
can  be  made  by  pinching  up  the  skin  and  transfixing  it  with  a  sharp- 
pointed  knife  or  by  "cutting  it  with  the  scissors.  The  cord  is  then 
hooked  up,  upon  the  finger,  out  of  the  loose,  fatty  layer  in  which  it 
lies,  and  with  one  or  two  strokes  of  the  knife  its  sheath  (the  spermatic 
fascia  and  the  fascia  propria)  is  opened.  The  vas  deferens  is  sought 
and  recognized,  and  together  with  the  immediately  adjacent  veins  is 
separated  from  the  other  parts  of  the  cord.  This  is  done  with  the 
fingers,  holding  the  vas  deferens  and  the  several  adjacent  vessels, 
artery  and  veins  of  the  vas,  which  are  to  be  allowed  to  remain  securely 
between  the  finger  and  thumb  of  the  left  hand,  while  the  work  of 


CT,  cavity  of  the  tunica 
vaginalis  testis. 

UV,  cremaster  artery  and 
artery  of  the  vas  deferens 
and  their  corresponding 
veins,  all  in  close  proxim- 
ity to  the  vas  deferens. 

IR,  internal  inguinal  ring — ■ 
the  mouth  of  the  original 
infundibular  process — 
through  which  the  struct- 
ures that  constitute  the 
cord  escape  (the  infundib- 
ular process  becomes  con- 
tracted around  the  ele- 
ments of  the  cord  and 
forms  their  proper  sheath 
—the  fascia  propria  [red 
line]). 

P,  peritoneum  that  lines  the 
interior  of  the  abdomen. 

8,   symphysis  pubis. 

SAV,  spermatic  artery  and 
veins  (below,  along  the 
course  of  the  cord,  the 
spermatic  veins  consist  of 
a  plexus  of  intercom- 
municating branches — the 
pampiniform  plexus). 

TF,   transversalis  fascia. 

YD,  vas  deferens. 

VP,  remains  of  the  oblit- 
erated vaginal  process  of 
peritoneum  that  accom- 
panies the  testis  in  its 
descent  into  the  scrotum 
(the  arrow  indicates  the 
site  of  the  former  opening 
or  mouth  of  this  process). 


Fig.   199.— Spermatic  Cord. 


AP,  spermatic  artery  and 
pampiniform  plexus. 

FP,  fascia  propria  (sheath 
of  the  cord  and  original 
infundibular  process). 

VD,  vas  deferens  sur- 
rounded closely  by  the 
cremaster  artery  and 
artery  of  the  vas  deferens 
and  their  corresponding 
veins. 

VP,  remains  of  the  obliter- 
ated vaginal  process. 


Fig.   200.— Cross   Section   of  Spermatic   Cord. 


Fig.  201. — Exposure  of  Spermatic  Cord.  The  spermatic  cord  has  been 
hooked  up  out  of  the  incision  upon  the  finger,  and  its  sheath  incised  prepara- 
tory to  separating  the  vas  deferens  and  adjoining  vessels  from  the  other 
structures  of  the  cord. 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC.         459 

separating  the  other  structures  of  the  cord,  veins  of  the  pampiniform 
plexus  and  the  spermatic  artery,  from  the  vas  deferens,  may  be  accom- 
plished with  the  fingers  of  the  right  hand  (see  Fig.  203). 

After  the  vas  deferens,  together  with  the  several  immediately 
adjacent  veins,  has  been  isolated  for  a  distance  varying  from  one  to 
two  inches,  depending  upon  the  laxness  of  the  scrotum  and  the  length 
of  the  cord,  etc.,  a  double  catgut  ligature  is  passed  with  an  artery 
forceps  and  then  cut  so  that  we  have  two  ligatures.  These  ligatures, 
which  surround  all  those  structures  of  the  cord  that  have  been  sepa- 


Fig.  202. — Varicocele.  The  vas  deferens  and  adjoining  vessels  (A)  have 
been  separated  from  the  other  structures  of  the  cord — from  the  spermatic 
artery  and  pampiniform  plexus  (B).  Ligatures  have  been  tied  about  B  above 
and  below  preparatory  to  excising  the  intervening  portion. 

rated  from  the  vas  deferens,  etc.,  are  tied,  one  above  and  the  other 
below.  The  portion  intervening  is  excised  with  the  scissors,  not  too 
close  to  the  ligatures,  and  the  ends  of  the  ligatures,  which  have  been 
purposely  left  long,  are  then  tied  together,  in  this  way  bringing  the 
ends  of  both  stumps  into  apposition.  The  ends  of  these  two  portions 
may  be  still  further  secured  by  one  or  two  catgut  sutures,  which 
should  take  a  good  bite  through  the  whole  thickness  of  each  stump. 

The  portion  of  the  cord  which  is  stripped  away  from  the  vas 
deferens,  and  which  is  ligated  and  excised,  is  composed  of  all  the 
veins  of  the  pampiniform  plexus  and  the  spermatic  artery.  When 
the  vas  is  isolated,  the  artery  of  the  vas  deferens,  which  anastomoses 


460  HERNIA,  ETC. 

below  with  the  spermatic  artery,  and  the  cremasteric  artery,  together 
with  their  corresponding  veins,  go  with  it;  these  vessels  are  there- 
fore not  interfered  with,  and  they  are  sufficient  to  provide  for  the 
nutrition  of  the  testis  after  the  pampiniform  plexus  and  the  sper- 
matic artery  have  been  ligated. 

For  the  ligatures,  plain  catgut,  not  too  thick  (No.  1  or  2)  may 
be  used,  and  special  care  should  be  taken  to  apply  the  upper  ligature 
securely  that  it  may  not  slip,  as  this  would  result  in  a  very  free  hem- 
orrhage from  the  end  of  the  spermatic  artery. 

In  this  operation  one  not  only  ties  off  the  veins  of  the  pam- 
piniform plexus,  but  also  shortens  the  cord,  and  thus  draws  the  testis 
up,  a  result  which  is  much  to  be  desired.  Before  closing  the  incision 
in  the  skin  all  bleeding  points  should  be  clamped  and  ligated  or 
twisted,  and  the  'wound  should  be  dry.  The  edges  of  the  incision 
in  the  skin  are  brought  together  with  a  continuous  stitch  of  catgut, 
which  may  be  intracuticular. 

For  Hydrocele. — A  condition  in  which  the  tunica  vaginalis  is 
distended  with  serous  fluid.  The  testis  is  usually  found  in  the  lower, 
back  part  of  the  sac,  the  fluid  being  collected  above  and  in  front 
of  it. 

Punctuee  and  Injection. — This  is  suitable  for  simple  cases, 
and  for  those  where  tapping  has  not  been  previously  resorted  to. 
The  scrotum  is  grasped  in  the  left  hand,  in  order  to  make  it  tense 
and  to  steady  it.  A  fine  needle,  attached  to  a  hypodermic  syringe,  is 
introduced  through  the  anterior  wall  of  the  scrotum,  and  a  small 
quantity  of  the  fluid  drawn  off,  both  for  the  purpose  of  confirming 
the  diagnosis  and  to  demonstrate  the  fact  that  the  needle  is  in  the 
cavity  of  the  tunica  vaginalis.  The  hypodermic  needle  is  left  in  situ, 
its  end  free  in  the  cavity  of  the  tunica  vaginalis.  A  fairly  large 
trochar  is  then  thrust  through  the  bottom  of  the  scrotum  rather 
toward  the  front,  and  in  an  upward  direction  into  the  cavity  of  the 
tunica  vaginalis.  In  doing  this  one  should  remember  that  the  testis 
occupies  the  lower  back  part  of  the  sac.  With  the  trochar  in  the  cavity 
of  the  tunica  vaginalis  one  should  be  able  with  it  to  touch  the  hypo- 
dermic needle  previously  introduced  into  the  sac  above.  The  sac  is 
allowed  to  empty  itself  through  the  cannula,  and  this  is  then  with- 
drawn. 

The  barrel  of  the  hypodermic  syringe  is  now  filled  with  the 
fluid  to  be  injected.  Twenty  minims  of  a  95-per-cent.  carbolic-acid 
solution  may  be  used,  with  satisfactory  results,  for  this  purpose. 


Fig.  203. — Varicocele.  Cord  separated  into  two  segments.  Finger  and 
thumb  of  left  hand  grasp  vas  and  adjacent  vessels,  artery  and  veins,  of 
vas  deferens.  '  Finger  and  thumb  of  right  hand  grasp  spermatic  artery  and 
veins  of  pampiniform  plexus. 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC. 


461 


This  is  thrown  into  the  cavity  of  the  tunica  vaginalis  through  the 
hypodermic  needle,  and  then  this  needle  is  also  withdrawn.  The 
fluid  that  has  heen  thus  introduced  into  the  cavity  of  the  tunica 
vaginalis  is  distributed  over  the  whole  cavity  by  manipulating  the 
scrotum.  The  punctures  made  by  the  instruments  are  covered  over 
with  a  thin  coat  of  collodion,  and  a  very  thin  film  of  absorbent 
cotton. 


Fig.  204.— Hydrocele,  Tapping.  CTT,  cavity  of  the  tunica  vaginalis  testis; 
T,  testis;  V,  vas  deferens.  Hypodermic  needle  introduced  into  the  upper  part 
of  the  sac;  trochar  cannula  into  the  lower  part. 


This  operation  is  usually  followed  by  some  effusion  into  the  sac, 
and  with  but  little  or  no  pain.  After  a  few  days'  rest  in  bed  with 
the  scrotum  supported,  these  symptoms  subside.  The  operation  is 
not  painful,  but  the  part  where  the  trochar  is  to  be  introduced  may 
be  anesthetized  with  ethyl  chloride  if  desired. 

Open  Opekation  (Volkmann). — This  operation  is  suitable  for 
those  cases  that  have  already  been  tapped  many  times  or  where  the 
operation  previously  described  has  been  tried  and  has  failed. 


462  HERNIA,  ETC. 

The  scrotum  is  grasped  by  an  assistant  in  order  to  make  it  tense 
and  to  steady  it.  An  incision  is  made  through  the  anterior  wall  of 
the  scrotum,  opening  into  the  cavity  of  the  tunica  vaginalis.  The 
length  of  the  incision  depends  upon  the  size  of  the  tumor,  but  is 
usually  two  or  three  inches.  When  the  tunica  vaginalis  has  been 
opened,  and  while  the  fluid  is  escaping,  the  edge  of  the  parietal  layer 
of  the  tunica  vaginalis — i.e.,  the  inner  lining  of  the  scrotal  sac — is 
seized  on  either  side  with  an  artery  forceps,  and  with  the  finger  this 
is  torn  away  from  its  attachment  to  the  inner  aspect  of  the  scrotum, 
and  excised  in  part  with  the  scissors.  If  the  tumor  has  been  very 
large,  it  will  be  necessary  to  excise  more  of  the  tunica  vaginalis  than 
if  the  tumor  is  smaller.  The  tunica  vaginalis  may  be  much  thick- 
ened. In  trimming  away  this  redundant  portion  of  the  tunica  vag- 
inalis one  must  take  care  to  leave  enough  to  conveniently  cover  the 
testis  and  also  avoid  cutting  into  the  epididymis.  It  is  rather  better 
to  excise  too  little  than  too  much  of  the  tunica  vaginalis.  After  this 
part  of  the  operation  has  been  done  the  edge  of  that  portion  of  the 
tunica  vaginalis  which  remains  is  fixed  to  the  corresponding  edge 
of  the  skin  incision  all  around  with  a  continuous  or  with  several 
interrupted  fine  catgut  sutures.  Then,  with  a  wad  of  cotton  on  a 
stick,  the  whole  interior  of  what  remains  of  the  tunica  vaginalis,  in- 
cluding that  covering  the  testis,  is  swabbed  out  with  95-per-cent. 
carbolic  acid.  The  cavity  is  then  loosely  packed  with  sterile  gauze. 
The  strips  should  reach  well  down  into  the  deepest  recesses  of  the 
cavity,  but  the  packing  should  not  be  tight.  A  loose  dressing  is 
applied,  which  may  be  held  in  place  by  a  T-bandage.  The  packing 
should  be  removed  at  the  end  of  forty-eight  hours,  simply  retaining 
a  strip  in  the  opening  in  the  skin,  and  the  parts  allowed  to  granulate. 
If  too  much  of  the  tunica  has  been  removed,  there  will  be  too  much 
inversion  of  the  skin,  and  this  will  delay  the  healing  process. 

Excision  of  the  Tunica  (von  Beegmann). — After  the  tunica 
vaginalis  sac  has  been  opened  and  its  contents  evacuated,  the  parietal 
layer  of  the  tunica  vaginalis  is  seized  and  stripped  away  from  its 
attachment  bluntly  with  the  fingers  as  far  back  as  the  posterior  bor- 
der of  the  testis,  or  rather  epididymis,  and  then  excised  in  its  en- 
tirety with  the  scissors.  After  all  bleeding  has  been  controlled  with 
forceps  and  ligatures,  the  wound  in  the  skin  is  closed  with  sutures, 
without  any  drainage  whatever.  As  a  rule,  the  skin  incision  heals 
by  first  intention,  and  the  patient  is  able  to  be  around  in  about  twelve 
days. 


Fig.  205.—  Volkmann  Operation  for  Hydrocele.     Edge  of  tunica  vaginalis  sutured 
to  the  edges  of  the  skin  incision. 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC.        463 

This  method  is  very  satisfactory,  and  is  especially  applicable  to 
those  cases  where  the  tunica  vaginalis  is  excessively  redundant  after 
the  evacuation  of  a  large  hydrocele,  or  when  the  tunica  is  markedly 
thickened. 

Ketroversion  of  the  Tunica  Vaginalis. — This  method  has 
been  variously  ascribed  to  Jaboulay,  Doyen,  Garampozzi,  and  Win- 
kelmann.  An  incision  is  made  in  the  front  of  the  scrotum,  usually 
about  two  inches  in  length,  into  the  cavity  of  the  tunica.  Through 
this  opening  the  fluid  contents  of  the  distended  tunica  vaginalis 
escape,  and  the  testis  is  then  drawn  forward  out  of  the  scrotum. 


Fig.  206.— Hydrocele.    Retroversion  of  the  tunica  vaginalis.    The  tunica  has  been 
turned  back  beyond  the  epididymis  and  fixed  there  by  sutures. 


As  the  testis  is  drawn  forward  out  of  the  scrotum,  the  vaginal 
layer  of  the  tunica  is  reflected  backward, — turned  inside  out,  as  it 
were, — so  that  the  opening  in  the  parietal  layer  of  the  tunica, 
through  which  the  testis  has  been  drawn,  gets  to  lie  behind  the  testis, 
encircling  the  cord  and  covering  over  the  epididymis,  and  in  this 
position  it  is  fixed  by  joining  its  edges  together  with  several  catgut 
sutures  so  that  it  may  not  again  slip  forward  over  the  testis.  The 
edges  of  the  incision  in  the  scrotum  are  now  sufficiently  detached  to 
allow  the  integument  of  the  scrotum  to  be  drawn  forward  and  cover 


464  HERNIA,  ETC. 

over  the  testis  and  reflected  tunica  vaginalis,  and  they  are  thus  united 
to  each  other  without  drainage,  in  this  way  completing  the  operation. 

The  result  of  this  operation  is  that  the  free  secreting  surface  of 
the  tunica  vaginalis  which  has  been  turned  inside  out  is  brought  into 
contact  with  the  raw  internal  wound  surface  of  the  scrotum,  to  which 
it  becomes  united,  effecting  the  cure. 

If  the  tunica  vaginalis  is  very  redundant  after  evacuating  a 
large  hydrocele,  a  part  of  the  tunica  may  be  excised  with  the  scissors, 
leaving  just  enough  to  complete  the  operation  as  described  above;  but 
for  those  very  large  hydroceles,  and  those  with  a  markedly  thickened 
tunica,  the  von  Bergmann  is  probably  the  more  satisfactory  opera- 
tion. 

Castration  (Extirpation  of  the  Testis). — An  incision,  about  two 
inches  long,  is  made  upon  the  front  of  the  upper  part  of  the  scrotum 
through  the  skin  and  fat,  commencing  at  a  point  just  below  the  ex- 
ternal ring — the  spine  of  the  pubes.  If  operating  for  malignant  dis- 
ease, and  if  the  skin  is  involved,  the  incision  may  be  arranged  so  as 
to  circumscribe  that  part  of  the  skin  which  is  involved.  In  the  upper 
part  of  the  incision  the  cord  is  found,  and  hooked  up,  upon  the  finger, 
and  just  below  the  point  where  it  emerges  from  the  external  ring  its 
sheath  is  incised  with  the  point  of  the  knife.  The  vas  deferens  is  then 
recognized,  and  should  be  separated  from  the  rest  of  the  cord.  A 
catgut  ligature  is  then  passed  about  those  parts  of  the  cord  which 
have  been  separated  from  the  vas  deferens,  and  tied  so  tightly 
that  it  cannot  slip  off.  This  ligature  should  include  all  the  elements 
of  the  cord  except  the  vas  deferens.  The  ends  of  this  ligature  are 
left  long,  to  serve  as  a  tractor;  the  cord,  including  the  vas  deferens, 
is  then  divided  with  the  scissors,  at  least  half  an  inch  below,  distal 
to  the  ligature.  Before  dividing  the  cord  it  is  grasped,  below  the 
point  at  which  it  is  to  be  divided,  with  an  artery  clamp.  The  cord 
having  been  divided,  the  lower  end,  that  which  is  held  in  the  grasp 
of  the  artery  forceps,  together  with  the  testis,  and  including  the  tunica 
vaginalis,  is  enucleated  from  the  scrotum,  usually  without  opening 
into  the  cavity  of  the  tunica  vaginalis,  and  almost  entirely  by  blunt 
dissection.  Where  the  knife  or  scissors  is  used  to  assist  in  this  enu- 
cleation one  should  take  care  not  to  cut  through  the  septum  into 
the  other  half  of  the  scrotum,  and  one  should  also  avoid  button-holing 
the  skin. 

After  the  testis  has  been  enucleated  we  return  to  the  stump  of 
the  cord.    This  may  be  brought  into  view  by  drawing  upon  the  liga- 


Fig.  207. — Castration.  Cord  has  been  divided.  The  end  of  the  lower  por- 
tion grasped  with  an  artery  forceps.  A  ligature  has  been  tied  around  the  end 
of  the  upper  stump.  It  will  be  noticed  that  the  vas  deferens  is  not  included  in 
the  ligature. 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC.         465 

ture,  which  was  left  long  to  serve  as  a  tractor,  and  if  there  is  no  bleed- 
ing this  ligature  may  be  cut  short  and  the  stump  of  the  cord  allowed 
to  retract  up  into  the  inguinal  canal.  Should  there  be  any  bleeding 
points,  these  may  be  clamped  and  ligated.  One  should  avoid  includ- 
ing the  stump  of  the  vas  deferens  in  the  ligature,  as  it  may  result  in 
disagreeable  symptoms;   e.g.,  colicky  pain,  etc. 

The  wound  is  large,  and  may  be  closed  with  catgut  sutures;  in 
most  cases,  however,  it  is  well  to  place  a  drain  in  the  lower  end  of  the 
wound.  If  operating  for  tuberculosis,  the  cord  should  be  divided  as 
high  up  as  one  can  reach. 


PART   VIII. 

THE  URINARY  SYSTEM. 


THE  KIDNEYS. 

The  Surgical  Anatomy  of  the  Kidney. — One  kidney  may  be  absent 
in  apparently  normal  subjects,  the  left  more  frequently  than  the  right. 
This  is  said  to  occur  once  in  about  two  thousand  four  hundred  sub- 
jects. Absence  of  one  kidney  has  been  met  with  twice  in  five  hundred 
subjects  in  the  writers  experience.  When  one  kidney  is  absent  that 
which  is  present  is  usually  larger  and  assumes  the  function  of  both 
kidneys. 

There  may  be  two  kidneys  present,  joined  together  below  or 
above,  horseshoe  kidney,  or  both  above  and  below,  either  with  con- 
nective tissue  or  kidney  tissue.  This  condition  is  met  with  about 
once  in  one  thousand  subjects. 

At  times  the  kidney  becomes  loosened  in  its  bed,  and  may  become 
dislodged, — movable  kidney, — or  it  may  be  provided  with  a  nearly 
complete  peritoneal  covering  and  mesentery  and  enjoy  a  considerable 
range  of  motion,  when  it  is  called  "floating,  or  wandering,"  kidney. 

The  kidneys  lie  in  the  upper  back  part  of  the  abdomen,  one  on 
each  side  of  the  vertebral  column,  from  the  twelfth  dorsal  to  the  third 
lumbar  vertebra.  They  are  extraperitoneal  organs,  being  covered  by 
peritoneum  upon  their  anterior  surface  only. 

The  kidneys  are  provided  with  a  fibrous  capsule,  which  is  usually 
very  thin  and  closely  adherent  to  the  organ.  They  are  lodged  within 
a  bed  of  loose  fat  and  connective  tissue,  out  of  which  they  may  be 
readily  enucleated.  The  anterior  surface  of  the  kidney  is  directed  for- 
ward and  outward,  and  is  covered  by  the  peritoneum.  The  descending 
part  of  the  duodenum  lies  in  front  of  the  right  kidney,  the  pancreas 
in  front  of  the  left  kidney. 

The  upper  part  of  the  posterior  surface  of  the  kidney  is  separated 
from  the  eleventh  and  twelfth  ribs  by  the  diaphragm  and  pleura;  the 
lower  part  of  the  posterior  surface  of  the  kidney  rests  upon  the  quad- 
ratus  hrmborum  muscle,  which  is  covered  by  the  anterior  layer  of  the 
lumbar  fascia.  Normally  the  upper  half  of  the  kidney  lies  above  the 
twelfth  rib,  and  the  lower  half  below  the  twelfth  rib. 
(466) 


OPERATIONS  UPON  THE  KIDNEY.  467 

The  inner  border  of  the  kidney  is  concave,  and  is  directed  toward 
the  psoas  muscle  and  the  vertebral  column;  the  inner  border  of  the 
kidney  really  rests  upon  the  edge  of  the  psoas  muscle,  and  the 
kidney  is  thus  tilted  somewhat  outward.  Corresponding  to  the  inner 
border  of  the  kidney  are  the  artery  and  vein  and  the  ureter.  At  the 
hilum  the  relation  of  these  structures  from  before  backward  is  vein, 
artery,  and  ureter;  upon  the  left  side  the  artery  lies  above  the  vein, 
and  upon  the  right  side  the  vein  lies  above  the  artery;  upon  both  sides 
the  ureter  is  the  lowest  of  the  three  structures. 

The  outer  border  of  the  kidney  is  rounded  and  convex,  and  is 
related,  the  right,  with  the  ascending  colon,  and  the  left  with  the 
descending  colon.  The  colon  really  lies  a  little  in  front  of  the  kidney, 
as  well  as  to  its  outer  side. 

The  upper  end  of  the  kidney  is  covered  by  the  suprarenal  cap- 
sule, which  sits  upon  it  like  a  cap.  The  upper  end  of  the  right  kidney 
is  in  close  relation  with  the  under  surface  of  the  liver.  The  upper 
end  of  the  left  kidney  lies  close  to  the  spleen.  The  lower  end  of  the 
kidney  reaches  to  within  one  or  two  inches  of  the  crest  of  the  ilium. 

The  right  kidney  is  located  about  one  inch  lower  than  the  left, 
and  this  is  due  to  the  presence  of  the  liver  upon  the  right  side;  the 
right  kidney  is,  therefore,  more  accessible  than  the  left,  and  this  is 
also  the  one  which  is  more  frequently  movable  and  the  object  of 
operative  measures. 

OPERATIONS  UPON  THE  KIDNEY. 

Nephropexy. — Suture  or  fixation  of  a  movable  or  floating  kidney. 

A  movable  kidney  is  one  that  enjoys  a  limited  range  of  motion 
in  the  posterior  part  of  the  abdomen,  but  which  does  not  leave  the 
lumbar  region.  A  floating  kidney  is  one  that  is  more  or 'less  com- 
pletely invested  with  a  peritoneal  coat  and  provided  with  a  more 
or  less  complete  mesonephron,  and  therefore  enjoys  a  considerable 
range  of  motion,  and  is  capable  of  leaving  the  lumbar  region  entirely. 

In  operating  upon  the  kidney  through  the  lumbar  incision  the 
patient  may  be  placed  prone  upon  the  table  with  an  Edebohls  cushion 
under  the  abdomen,  or  he  may  rest  upon  the  side  of  the  body  corre- 
sponding to  the  kidney  which  is  not  the  object  of  operation,  with 
the  knees  and  thighs  somewhat  flexed  and  the  front  of  the  body 
turned  toward  the  table.  In  this  latter  position  the  patient  is 
steadied  with  sand  bags  placed  against  the  chest  and  abdomen;    an- 


463 


URINARY  SYSTEM. 


other  sand  bag  or  cushion  may  be  placed  between  the  lower  part  of 
the  side  of  the  chest  and  the  table,  with  the  idea  of  increasing  the 
space  between  the  lower  border  of  the  twelfth  rib  and  the  crest  of 
the  ilium  upon  the  side  of  operation. 

It  is  important  that  the  abdomen  be  relaxed  in  order  that  the 
assistant  during  the  operation  may  be  able  through  the  abdominal  wall 
to  push  the  kidney  upward  toward  the  incision  in  the  loin.  Probably 
the  most  satisfactory  position  is  with  the  patient  lying  prone  upon  the 


^_ 


Fig. 


208. — Incision  to  Expose  Kidney.     A,   along  the  edge  of  the  erector 
spinas.    A',  additional  incision  along  the  edge  of  the  last  rib. 


table  with  the  Edebohls  cushion  under  the  abdomen,  especially  if  both 
kidneys  are  to  be  exposed  during  the  operation. 

The  incision  corresponds  to  the  outer  border  of  the  erector 
spina?  muscle,  commencing,  above,  just  below  the  twelfth  rib,  about 
two  and  a  half  inches  from  the  middle  line  (spinous  processes);  it 
passes  downward,  curving  somewhat  outward,  and  terminates  just 
above  the  crest  of  the  ilium.  This  incision  should  extend  through 
the  skin  and  subcutaneous  fat  down  to  the  surface  of  the  latissimus 
dorsi,  the  fibers  of  which  muscle  are  exposed.  The  incision  is  then 
carried  through  the  fibers  of  the  muscle,  when  the  outer  border  of 


OPERATIONS  UPON  THE  KIDNEY.  469 

the  erector  spinas  may  be  recognized;  without  opening  its  sheath, 
this  muscle  is  drawn  toward  the  middle  line  with  retractors.  The 
quadratus  lumborum,  covered  by  its  layer  of  lumbar  fascia,  is  then 
exposed  in  the  bottom  of  the  wound.  The  fascia  that  covers  the 
quadratus  lumborum  is  incised  along  the  outer  border  of  the  mus- 
cle, which  is  then  also  drawn  toward  the  spine.  It  is  important 
to  recognize  the  edge  of  this  muscle.  One  should  be  on  the  lookout 
for  the  ilio-hypogastric  nerve,  which  is  derived  from  the  lumbar 
plexus  and  passes  downward  and  outward  across  the  front  of  the 
quadratus  lumborum;  this  nerve  is  usually  seen  after  the  edge  of  the 
quadratus  lumborum  has  been  exposed,  and  should  not  be  cut,  but 
rather  drawn  aside,  out  of  the  way. 

There  remains  now  only  the  deepest  and  last  layer  of  the  lum- 
bar fascia  to  incise,  and  this  should  be  split  the  full  length  of  the 
skin  incision.  In  cutting  through  the  various  layers  of  the  back, 
if  the  patient  rests  upon  the  side,  there  is  a  tendency  to  work  in- 
ward, toward  the  spinal  column,  instead  of  directly  downward, 
through  the  different  layers,  toward  the  kidney,  and  this  should  be 
avoided.  The  incision  should  reach  above  to  the  lower  border  of  the 
last  rib,  but  should  not  be  carried  beyond  this  level  by  carelessly 
passing  the  point  of  the  knife,  within  the  wound,  upward  under- 
neath the  last  rib,  as  the  pleural  cavity  may  be  thus  accidentally 
opened. 

After  having  cut  through  the  deepest  and  last  layer  of  lumbar 
fascia,  the  fatty  capsule,  in  which  the  kidney  is  imbedded,  is  en- 
countered. This  is  separated  from  the  kidney  bluntly,  with  the 
fingers  in  the  wound,  in  order  to  bring  the  kidney  into  the  incision 
for  fixation. 

During  this  step  of  the  operation  one  should  be  careful  not  to 
penetrate  through  the  proper  fibrous  capsule  of  the  kidney,  since, 
if  this  accident  occurs,  one  may  detach  the  true  capsule  of  the  kidney 
from  the  kidney  substance  proper,  instead  of  isolating  the  kidney 
with  its  proper  capsule  intact  from  the  loose  mass  of  fat  in  which 
it  is  lodged.  If  the  kidney  is  displaced,  movable,  it  is  easy  to  reach  it, 
as  it  then  lies  lower  in  the  abdomen.  The  right  kidney  normally 
is  situated  lower  than  the  left.  When  the  kidney  is  sufficiently  free, 
its  outer,  rounded  border  is  brought  up  into  the  wound;  this  is 
greatly  facilitated  by  the  assistant  forcing  it  up  by  pressure  from 
the  front  of  the  abdomen  if  the  patient  lies  upon  the  side.  If  the 
patient  lies  prone,  with  the  Edebohls  cushion  under  the  abdomen, 


470  URINARY  SYSTEM. 

the  kidney  may  be  brought  into  the  wound  or  entirely  out  upon  the 
back  without  any  counter-pressure  being  made  upon  the  abdomen 
from  in  front. 

The  proper  fibrous  capsule  is  incised  from  above  downward 
along  the  whole  length  of  the  outer,  rounded  border  of  the  kidney, 
and  each  edge  seized  and  separated  from  the  kidney  substance — it 
peels  off  easily — for  a  distance  of  about  one  inch  on  each  side. 

Either  edge  of  the  detached  capsule  is  then  sutured  above  and 
below  with  chromicized  catgut  to  the  corresponding  edge  of  the 
muscles  deep  in  the  wound.  Two  additional  sutures  of  No.  2  chro- 
micized catgut  are  passed  through  the  edges  of  the  muscles  and  car- 
ried deep  through  the  kidney  tissue  proper:  one  of  these  sutures  passes 
through  the  upper  part  of  the  kidney  and  one  through  the  lower  part. 
It  is  probably  more  convenient  to  pass  these  two  deep  kidney  sutures 
first,  leaving  them  untied,  to  be  used  as  tractors  to  hold  the  kidney  in 
position  until  the  stitches  through  the  capsule  have  been  introduced 
and  tied.  The  two  deep  stitches  are  then  tied  also,  but  not  too  tight,  as 
they  might  cut  through  the  kidney  tissue.  When  all  the  sutures  have 
been  tied,  it  will  be  seen  that  the  external,  rounded  border  of  the 
kidney,  denuded  of  its  capsule,  is  firmly  fixed  to  the  edges  of  the 
muscles  deep  in  the  wound,  and  in  this  position  it  remains  fixed  as 
the  wound  heals.  Before  tying  the  two  sutures  that  pass  through 
the  kidney  the  edges  of  the  muscles  in  the  incision  may  be  united  by 
several  deep  catgut  stitches. 

The  incision  is  closed  with  interrupted  silk-worm  gut  stitches, 
which  pass  deep  through  both  the  skin  and  muscles,  or  the  muscles 
may  be  united  separately  by  several  deep,  interrupted,  catgut  su- 
tures.    It  is  unnecessary  to  drain  the  wound. 

There  are  usually  no  large  vessels  encountered  during  the  op- 
eration, but  any  spurting  points  may  be  clamped  and  ligated. 

Nephropexy  (Edebohls).  —  An  incision  is  made  which  reaches 
from  the  twelfth  rib  to  the  crest  of  the  ilium  along  the  outer  border 
of  the  erector  spinse;  it  passes  through  the  skin  and  fat  down  to  the 
latissimus  dorsi.  The  fibers  of  the  latissimus  dorsi  are  not  cut,  but 
are  separated  bluntly,  in  the  direction  of  their  course,  with  the 
handle  of  the  knife. 

Corresponding  to  the  outer  edge  of  the  quadratus  lumborum 
muscle,  which  lies  beneath  the  erector  spinse,  the  transversalis  fascia 
is  incised,  thus  entering  the  abdomen  and  exposing  the  mass  of  fat 
(fatty  capsule)   within  which  the  kidney,  enveloped  in  its  proper 


OPERATIONS  UPON  THE  KIDNEY.  471 

fibrous  capsule,  is  imbedded.  One  should  avoid  division  of  the  ilio- 
hypogastric nerve,  a  moderately  large  branch  of  the  lumbar  plexus 
which  passes  obliquely  downward  and  outward  across  the  front  sur- 
face of  the  quadratus  lumborum;.  it  should  be  sought  for  at  the 
outer  edge  of  the  quadratus  lumborum,  and  drawn  to  one  side. 

Upon  its  anterior  aspect  and  near  its  outer  edge  the  sheath  of 
the  quadratus  lumborum  is  now  incised  from  the  twelfth  rib  to  the 
crest  of  the  ilium;  this  exposes  a  considerable  area  of  the  raw  ante- 
rior surface  of  the  muscle.  With  the  fingers  in  the  wound  the  fatty 
capsule  is  peeled  off  the  kidney,  and  the  organ,  enveloped  in  its  proper 
fibrous  capsule,  is  delivered  through  the  wound  out  upon  the  back. 
At  times  the  kidney,  still  enveloped  in  its  fatty  capsule,  may  be  de- 
livered through  the.  wound,  and  under  these  circumstances  the  fatty 
capsule  may  be  separated  from  the  kidney  almost  as  far  as  the  pelvis, 
and  excised  with  the  scissors. 

The  position  of  the  patient,  prone,  and  with  the  Edebohls 
cushion  underneath  the  abdomen,  makes  the  delivery  of  the  kidney 
comparatively  easy.  If  the  opening  in  the  loin  is  not  sufficiently 
roomy,  it  may  be  enlarged  by  nicking  the  outer  edge  of  the  quad- 
ratus lumborum  below,  near  its  attachment  to  the  ilium. 

A  small  incision  is  made  in  the  capsule  of  the  kidney,  near  the 
middle  of  its  outer,  rounded  border,  and  through  this  opening  a 
director  is  introduced  upon  which  the  capsule  is  divided  along  the 
entire  length  of  the  outer  border  of  the  kidney.  The  capsule  is  then 
peeled  back,  about  half-way  toward  the  pelvis  upon  either-  surface, 
thus  laying  bare  about  one-half  of  the  entire  kidney  surface.  The 
detached  part  of  the  capsule  is  not  excised  unless  it  is  quite  redun- 
dant; it  is  simply  folded  back  toward  the  pelvis  of  the  kidney  upon 
the  non-detached  portion. 

Four  fixation  sutures  of  forty-day  chromicized  catgut  are  now 
introduced  through  the  capsule;  these  pass  through  the  capsule 
only,  two  on  each  side,  one  above  and  the  other  below.  Each  of 
these  fixation  sutures  should  take  a  good,  broad  bite,  and  passes 
through  both  the  detached  and  the  non-detached  portions  of  the 
capsule,  parallel  with  and  close  to  the  margin  that  corresponds  to 
the  line  of  its  reflection.  After  these  four  fixation  sutures  have  been 
introduced  the  kidney  is  returned  into  the  abdomen. 

The  ends  (eight  in  number)  of  the  fixation  sutures  are  then,  in 
succession,  one  after  the  other,  threaded  in  a  large  curved  Hagedorn 
needle,  and  carried  through  the  muscles  and  fascia  that  correspond 


472 


URINARY  SYSTEM. 


to  the  edges  of  the  incision,  from  within  outward.  The  sutures  are 
not  tied  until  later.  Those  sutures  that  pass  through  the  inner 
edge  of  the  incision  penetrate  the  retracted  edge  of  the  incised  sheath 
of  the  quadratus,  the  quadratus  itself,  and  the  erector  spinse  and 
latissimus  dorsi;  the  sutures  that  pass  through  the  outer  edge  of 
the  incision  pierce  the  edge  of  the  transversalis  fascia  and  the  latis- 
simus dorsi  muscle. 

Now,  before  tying  the  fixation  sutures  the  edges  of  the  wound 
in  the  back  are  approximated  with  from  four  to  six  chromicized  cat- 


Fig.  209.— Nephropexy  (EdeboTils).  Kidney  delivered  through  an  incision 
in  the  back.  Proper  fibrous  capsule  reflected  and  two  fixation  sutures  intro- 
duced, one  above  (A,  A')  and  one  below  (B,  B').  These  sutures  pass  through 
the  reflected  and  attached  portions  of  the  capsule  close  to  the  line  of  reflec- 
tion. The  two  sutures  that  secure  the  capsule  upon  the  opposite  side  of 
kidney  are  not  seen. 


gut  sutures;  these  are  interrupted,  and  pass  through  all  the  fasciae 
and  muscles  in  the  edges  of  the  wound.  The  fixation  sutures  are 
then  tied;  they  emerge  upon  the  posterior  surface  of  the  latissimus 
dorsi,  four  upon  each  side  of  the  line  of  division  in  the  muscle.  They 
are  not  tied  across  the  wound,  but  the  adjoining  ones  of  each  side 
are  tied  to  each  other  upon  the  same  side  of  the  wound. 

The  edges  of  the  skin  are  finally  united  without  drainage  with 
an  intracuticular  suture. 

The  result  of  this  operation  is  to  fix  the  denuded,  raw  surface 


OPERATIONS  UPON  THE  KIDNEY.  473 

of  the  kidney,  corresponding  to  the  whole  length  of  its  convex  bor- 
der, and  extending  half  way  to  the  pelvis  npon  either  surface,  to  the 
denuded  anterior  surface  of  the  quadratus  lumborum,  the  upper  ex- 
tremity of  the  kidney  projecting  upward,  beneath  the  last  ribs. 

Nephrotomy. — Cutting  into  the  kidney  for  the  purpose  of  evac- 
uating an  abscess  or  to  explore  the  pelvis  of  the  kidney. 

The  position  of  the  patient  and  the  incision  are  as  described  for 
nephropexy  (page  467).  The  patient  is  placed  either  prone,  with  the 
Edebohls  cushion  underneath  the  abdomen,  or  else  he  rests  upon 
the  well  side.  The  incision  is  carried  down,  step  by  step,  until  the 
last  layer  of  the  lumbar  fascia  has  been  cut  and  the  kidney  is  reached. 
If  operating  for  nephritic  abscess,  we  may  find,  as  soon  as  the  kidney 
is  exposed,  that  the  indications  of  the  abscess  immediately  present 
themselves,  or  it  may  be  necessary  to  search  with  an  exploring  needle. 
When  pus  is  located,  the  cavity  containing  it  is  incised  with  the  point 
of  the  scalpel  and  enlarged  with  dressing  forceps,  which  are  intro- 
duced closed  and  expanded  as  they  are  withdrawn.  At  times  the 
entire  kidney  substance  is  destroyed,  and  simply  a  bag  of  pus  re- 
mains. We  may  or  may  not  find  a  stone.  The  abscess  cavity  is  irri- 
gated and  packed  loosely  with  a  strip  of  iodoform  gauze,  the  end  of 
which  emerges  through  the  lower  part  of  the  wound  in  the  loin. 

In  closing  the  incision  in  the  back  the  stitches  should  be  carried 
deep  in  order  to  include  the  muscles,  together  with  the  skin;  the 
lower  part  is  left  open  for  drainage. 

At  times,  in  order  to  explore  the  pelvis  of  the  kidney  or  to 
drain  it,  it  may  be  necessary  to  bisect  or  split  the  kidney  from  its 
posterior  rounded  border  right  through  into  its  pelvis.  In  doing 
this  care  should  be  exercised  to  divide  the  kidney  midway  between 
its  two  surfaces,  as  this  is  attended  with  less  hemorrhage.  The 
kidney  must  be  brought  up  into  the  wound,  and  may  be  steadied 
there  by  an  assistant  exercising  pressure  from  in  front.  It  is  usually 
sufficient  if  the  incision  in  the  kidney  extends  through  only  a  part 
of  its  length.  In  this  way  a  stone  which  may  escape  the  exploring 
needle  may  be  detected  and  removed,  or,  if  there  is  no  stone  present, 
and  the  symptoms  are  due  to  an  inflammatory  condition  of  the  pelvis, 
this  may  be  drained  through  the  kidney  by  leaving  a  small  tube  or 
a  strip  of  iodoform  gauze,  which  reaches  from  the  pelvis  of  the  kid- 
ney and  emerges  through  the  incision  in  the  loin.  A  resulting  urinary 
fistula  usually  closes  spontaneously,  provided  the  ureter  is  not  ob- 
structed. 


474  URINARY  SYSTEM. 

The  cut  surfaces  of  the  kidney  may  be  brought  together,  thus 
controlling  hemorrhage  from  the  renal  vessels,  by  passing  several 
deep  sutures  through  the  substance  of  the  kidney.  If  an  individual 
spurting  artery  of  some  size  is  seen,  it  should  be  ligated  separately. 
For  these  sutures  catgut  should  be  used,  and  they  should  be  passed 
in  a  curved  surgeon's  needle. 

The  wound  in  the  loin  is  closed  in  part  by  interrupted,  silk- 
worm gut  sutures,  which  penetrate  deep  through  the  edges  of  the 
muscles,  or  the  edges  of  the  muscles  may  be  united  separately  by 
several  interrupted  catgut  sutures. 

Nephrolithotomy. — Cutting  into  the  kidney  for  stone. 

The  steps  of  this  operation  are  like  those  already  described  in  the 
preceding  operation.  After  the  kidney  has  been  reached  and  brought 
up  into  the  wound  it  may  be  palpated  and  punctured  with  a  fine 
needle,  here  and  there,  in  order  to  locate  the  stone.  It  may  be  found 
in  the  pelvis  of  the  kidney  or  in  the  kidney  tissue  proper.  With  the 
point  of  the  knife,  which  is  passed  along  the  needle  as  a  guide,  an 
incision  is  made  in  the  kidney,  this  opening  being  enlarged  with  an 
artery  forceps,  or  the  pelvis  of  the  kidney  may  be  incised,  and  the  stone 
extracted. 

If  one  is  unable  to  locate  the  stone  with  the  exploring  needle, 
and  the  symptoms  warrant  it,  the  kidney  may  be  laid  open,  as  in 
the  preceding  operation. 

As  a  rule,  pus  is  associated  with  stone,  and  it  is,  therefore,  usu- 
ally necessary  to  drain  these  cases. 

If  there  is  no  pus,  or  if  small  in  quantity  and  if  the  ureter  is  not 
obstructed,  one  may  omit  drainage  and  allow  the  wound  in  the  kid- 
ney to  close;  if  the  opening  is  large,  a  suture  may  be  introduced. 
If  the  pelvis  of  the  kidney  has  been  opened,  it  may  be  closed  with 
several  catgut  sutures  introduced  with  a  small,  curved  needle  in  a 
holder.  It  is  well  to  provide  drainage  for  the  incision  in  the  back,  a 
strand  of  gauze  being  packed  into  the  wound  down  to  the  site  of  the 
incision  in  the  kidney  or  pelvis  of  the  kidney. 

Nephrectomy. — Extirpation  of  the  kidney. 

The  position  of  the  patient  is  the  same  as  that  already  described 
for  nephropexy.  The  steps  of  the  operation  are  as  above  indicated 
down  to  the  point  of  exposing  the  kidney.  The  incision  is  the  same 
as  that  described  for  nephropexy  (page  467)  and  should  reach  from 
the  last  rib  to  the  crest  of  the  ilium.  If  necessary,  we  may  obtain 
more  room  by  curving  the  lower  end  of  the  incision  forward,  above  the 


OPERATIONS  UPON  THE  KIDNEY.  475 

upper  border  of  the  crest  of  the  ilium,  or  Ave  may  make  a  cut  from 
the  upper  end  of  the  lumbar  incision  outward  along  the  lower  border 
of  the  last  rib  (see  Fig.  208). 

The  isolation  of  the  kidney  must  be  thorough,  and  this  is  ac- 
complished with  the  hand  in  the  wound,  working  patiently,  with  the 
fingers,  around  the  kidney,  care  being  taken  not  to  tug  upon  the 
kidney,  as  one  may  tear  the  vessels  at  the  hilum.  The  suprarenal 
capsule  may  be  left  behind,  although,  if  diseased,  it  may  be  removed 
also.  After  the  kidney  has  been  isolated,  its  outer,  rounded  border 
is  brought  well  into  the  wound,  or,  as  may  be  done  in  nearly  all 
cases,  the  kidney  is  brought  entirely  out  of  the  wound,  so  that  a  liga- 
ture may  be  thrown  around  it  and  worked  down  about  the  structures 
at  the  hilum — the  vein,  artery,  and  ureter — and  tied,  or  one  may  pass 
the  ligature  with  a  large,  curved,  blunt  ligature  carrier,  the  ligature 
being  carried  about  the  artery  and  vein,  without  including  the  ureter, 
which  lies  below  the  vessels  and  on  a  plane  posterior  to  them. 

The  ligature  should  be  of  strong  catgut;  after  the  ligature  has 
been  tied  its  ends  should  not  be  cut  short,  as  it  is  desirable  to  use  the 
ligature  as  a  tractor  to  bring  the  stump  of  the  kidney  into  view  for  final 
inspection. 

In  cutting  away  the  kidney  the  division  should  not  pass  through 
the  pedicle,  which  is  made  of  the  vessels,  but,  if  possible,  should  pass 
through  the  kidney  tissue  near  the  hilum,  in  order  to  leave  a  little 
mass  of  kidney  tissue  as  a  cap,  or  knob,  to  prevent  the  slipping  of 
the  ligature. 

The  wound  is  treated  as  in  the  foregoing  operations;  it  is  prob- 
ably better  to  introduce  a  drain,  which  is  left  for  seventy-two  hours. 

When  the  kidney  is  the  seat  of  a  very  large  tumor,  it  may  be 
difficult  to  remove  it  through  this  posterior  incision. 

We  should  be  positive  that  a  second  kidney,  which  is  capable 
of  carrying  on  the  work,  is  present,  and,  if  necessary  at  the  time  of 
the  operation,  an  incision  may  be  made  down  upon  the  other  kidney 
in  order  to  satisfy  ourselves  of  its  presence. 

Decortication  of  the  Kidney  (Edebohls).  —  This  operation  was 
first  suggested  for  the  cure  of  chronic  Bright's  disease,  by  Edebohls. 
The  operation  is  recent,  and  its  real  value  still  sub  judice.  The  bene- 
ficial effect  of  the  operation  is,  no  doubt,  due  to  the  increased  supply 
of  blood  that  is  brought  to  the  kidney  through  the  new  vascular  con- 
nections that  are  formed  between  it  and  the  adjacent  parts. 

Edebohls  says  that  one  may  use  the  anaesthetic,  ether  or  chloro- 


476  URINARY  SYSTEM. 

form,  with  which  he  is  most  familiar.  Mixed  nitrous  oxide  and  oxygen 
is  very  well  adapted  to  certain  cases.  It  would  seem  that  chloroform 
would  be  more  satisfactory  in  most  cases.  Spinal  analgesia  would,  no 
doubt,  be  appropriate  in  some  of  these  cases,  where  the  patient's  con- 
dition counter-indicates  the  use  of  a  general  anaesthetic. 

The  patient  lies  prone  upon  the  table,  with  the  Edebohls  cushion 
under  the  abdomen.  The  incision,  the  same  as  that  described  for 
nephropexy  (page  467),  corresponds  to  the  edge  of  the  erector  spinas, 
and  penetrates  the  transversalis  fascia  along  the  outer  edge  of  the 
quadratus  lumborum.  The  kidney  is  recognized  in  the  mass  of  fat, 
fatty  capsule,  that  incloses  it. 

"With  the  fingers  in  the  wound  the  fatty  capsule  is  separated 
bluntly  from  the  surface  of  the  kidney  as  far  as  the  pelvis.  The  kid- 
ney, inclosed  within  its  unbroken  fibrous  capsule,  is  then  drawn  into 
the  wound,  or,  if  possible,  lifted  out  of  the  wound  upon  the  back. 

Corresponding  to  the  middle  of  the  outer,  rounded  border  of  the 
kidney,  the  capsule  proper  is  incised,  and  divided  upon  a  director 
along  the  entire  length  of  the  outer,  rounded  border  of  the  organ,  and 
around  its  extremities,  above  and  below.  Each  half  of  the  capsule  is 
then  stripped  away  from  the  surface  of  the  kidney  toward  the  pelvis, 
taking  care  not  to  break  or  tear  the  kidney  substance  proper,  which 
may  be  friable  and  firmly  adherent  to  the  capsule. 

The  stripped  off  capsule  is  finally  cut  away  near  the  pelvis  of  the 
kidney,  and  removed.  If  the  kidney  cannot  be  brought  out  through 
the  incision  in  the  back,  the  capsule  must  be  peeled  off  the  kidney, 
with  the  fingers  in  the  wound,  and  excised,  as  far  as  possible. 

Any  portion  of  the  capsule  that  still  remains  may  be  rolled  back 
toward  the  pelvis  of  the  kidney,  where  it  remains  coiled  up,  upon 
itself. 

The  kidney  is  finally  replaced  in  the  abdomen,  and  the  incision 
closed  without  drainage.  At  the  time  of  operation  it  may  appear  that 
but  one  kidney  is  the  seat  of  chronic  Bright's  disease,  but  it  is  prob- 
ably wise  in  all  cases  to  encapsulate  both  kidneys  at  the  same  sitting. 

THE  BLADDER. 

Surgical  Anatomy  of  the  Bladder. — The  bladder  is  a  hollow  mus- 
cular organ  whose  function  is  to  receive  and  hold  the  urine  during 
the  intervals  of  micturition.  It  has  a  capacity  ordinarily  of  about 
sixteen  ounces. 


SURGICAL  ANATOMY  OF  THE  BLADDER.  477 

In  the  infant  the  bladder  is  rather  conical,  and  projects  into  the 
abdomen  above  the  level  of  the  symphysis. 

In  the  adult  the  bladder,  when  empty,  lies  deep  within  the  pelvis 
behind  the  symphysis,  its  cavity  obliterated  and  its  walls  collapsed 
and  in  contact  with  each  other.  When  distended  moderately,  it 
reaches  as  high  as  the  symphysis,  farther  distension  causing  it  to  rise 
up,  out  of  the  pelvis,  into  the  abdominal  cavity  a  varying  distance 
toward  the  umbilicus.  When  it  is  distended  with  about  a  pint  of 
fluid,  the  bladder  is  pear-shaped,  and  reaches  for  a  distance  of  about 
four  inches  above  the  symphysis. 

The  body  of  the  bladder  is  free,  and,  when  the  organ  is  distended, 
rises  out  of  the  pelvis  into  the  abdomen,  toward  the  umbilicus. 

The  base  of  the  bladder  in  the  male  is  in  close  relation  with  the 
anterior  surface  of  the  second  part  of  the  rectum,  and  upon  its  inner 
aspect,  on  either  side,  shows  the  openings  of  the  ureters. 

The  neck  of  the  bladder  is  continuous  with  the  commencement 
of  the  urethra,  and  in  the  male  is  surrounded  by  the  prostate,  like  a 
collar. 

Eelations  of  the  Bladder.  In  the  Male  the  bladder  is  in  rela- 
tion, behind,  with  the  rectum,  the  base  of  the  bladder  lying  directly 
in  front  of  the  second  portion  of  this  part  of  the  bowel,  the  two  being 
joined  together  more  or  less  intimately  by  connective  tissue. 

The  seminal  vesicles  and  vas  deferens  are  located  on  either  side 
of  the  middle  line,  in  the  space  between  the  contiguous  walls  of  the 
rectum  and  the  bladder;  they  converge  anteriorly  toward  the  pros- 
tate, which  surrounds  the  neck  of  the  bladder,  and  which  is  readily 
felt  through  the  rectum. 

In  the  Female  the  uterus  and  vagina  are  located  behind  the 
bladder. 

In  both  sexes  the  bladder  lies  immediately  behind  the  symphysis 
pubis,  from  which  it  is  separated  by  a  space,  which  is  filled  with  loose 
connective  tissue  more  or  less  firmly  connected  with  the  anterior  wall 
of  the  bladder,  and  which  is  called  the  space  of  Eetzius.  When  the 
bladder  is  distended,  it  reaches  above  the  symphysis,  and  is  then  in 
relation,  in  front,  with  the  anterior  abdominal  wall. 

Passing  from  the  summit  of  the  bladder  to  the  umbilicus  is  the 
urachus,  which  occasionally  remains  patent  after  birth. 

The  peritoneum  covers  the  sides,  part  of  the  posterior  surface, 
and  the  summit  of  the  bladder,  but  does  not  cover  its  anterior  surface, 
being  reflected  from  the  summit  of  the  bladder  over  on  to  the  poste- 


47S 


URINARY  SYSTEM. 


rior  surface  of  the  anterior  abdominal  wall.  When  the  bladder  is 
well  distended,  it  rises  upward  into  the  abdomen;  its  summit,  as  it 
approaches  the  umbilicus,  carries  the  peritoneum  with  it,  and  its  ante- 
rior surface,  which  is  devoid  of  peritoneum,  then  comes  into  relation 
with  the  abdominal  wall;  so  that  under  these  circumstances  the  blad- 
der may  be  entered  through  an  incision  in  the  anterior  abdominal 
wall,  low  down,  close  to  the  symphysis,  without  molesting  the  peri- 
toneum or  entering  the  peritoneal  cavity. 


Fig.  210. —An  Antero-posterior  Section  Showing  Relations  of  the  Perito- 
neum to  the  Bladder,  etc.  Bladder  moderately  distended.  P,  prostate  gland 
surrounding  commencement  of  the  urethra  (neck  of  the  bladder) ;  PP,  ante- 
rior fold  of  peritoneum  reflected  from  the  posterior  aspect  of  the  anterior 
abdominal  wall  over  on  to  the  fundus  of  the  bladder;  8P,  symphysis  pubis; 
TS,  vesiculae  seminales. 


The  higher  the  bladder  ascends  into  the  abdomen,  the  larger  the 
area  of  its  anterior,  non-peritoneal  surface  which  is  presented  for 
operation. 

OPERATIONS  UPON  THE  BLADDER. 

Suprapubic  Cystotomy.  —  The  patient  is  placed  in  the  usual 
position  upon  the  back  and  fully  anaesthetized,  so  as  to  relax  the  ab- 
dominal muscles.     If  one  is  unable  to  distend  the  bladder,  owing  to 


OPERATIONS  UPON  THE  BLADDER.  479 

the  existence  of  an  impassable  stricture  of  the  urethra,  etc.,  much 
advantage  is  gained  by  placing  the  patient  in  the  Trendelenburg 
position. 

A  soft  rubber  catheter  is  introduced  into  the  bladder,  and, 
through  this,  the  bladder  is  washed  out  with  boric-acid  solution,  10  to 
12  ounces  being  allowed  to  remain;  the  catheter  is  then  withdrawn, 
and  a  band  tied  about  the  penis  to  prevent  the  escape  of  the  fluid. 
The  fluid  which  is  thrown  into  the  bladder  causes  it  to  ascend  into 
the  abdomen,  carrying  the  peritoneum  with  it;  so  that  its  anterior 
surface,  uncovered  by  peritoneum,  is  exposed  for  several  inches  for 
operation.  It  is  well  not  to  introduce  more  than  10  to  12  ounces,  as 
oftentimes  the  capacity  of  the  bladder  is  diminished,  and  a  quantity 
above  12  ounces  might  do  harm. 

In  order  to  throw  the  distended  bladder  farther  forward  toward 
the  anterior  abdominal  wall,  a  bag  may  be  introduced  into  the  rectum 
and  distended  with  about  6  ounces  of  water.  Most  operators  dispense 
with  the  rectal  bag  as  unnecessary.  The  incision,  which  is  placed  in 
the  middle  line,  linea  alba,  commences  below,  at  the  symphysis  pubis, 
and  reaches  upward,  toward  the  umbilicus,  for  a  distance  of  about 
three  inches,  and  extends  through  the  skin  and  fat  down  to  the  deep 
fascia.     Bleeding  vessels  in  the  skin  are  clamped. 

The  incision  is  carried  down  through  the  linea  alba,  between  the 
edges  of  the  recti  and  pyramidales,  until  the  layer  of  connective  tissue, 
which  is  located  in  front  of  the  bladder,  dipping  down  between  it  and 
the  symphysis  pubis,  is  reached. 

The  edges  of  the  wound  are  then  drawn  apart  with  retractors, 
and  this  layer  of  connective  tissue,  which  covers  the  anterior  wall  of 
the  bladder,  is  scraped  upward,  toward  the  umbilicus,  with  the  finger- 
nail; so  that,  in  case  the  fold  of  peritoneum  reaches  abnormally  low, 
or  the  bladder  has  not  been  sufficiently  distended,  we  may  thus  still 
separate  it  and  carry  it  upward  toward  the  umbilicus.  The  muscular 
wall  of  the  bladder  is  then  easily  recognized,  especially  if  the  organ  is 
distended.  A  plexus  of  veins,  more  or  less  visible,  which  ascends 
upon  the  anterior  wall  of  the  bladder  from  below,  may  help  to  identify 
it. 

With  a  curved  surgeon's  needle  two  rather  stout  silk  stitches  are 
introduced,  one  on  either  side  of  the  middle  line,  through  the  whole 
thickness  of  the  bladder  wall,  and  these  are  used  as  tractors  to  steady 
the  bladder  while  it  is  being  incised. 

In  cutting  into  the  bladder  the  point  of  the  knife  is  introduced 


4S0  URINARY  SYSTEM. 

between  the  two  silk  tractor  stitches  about  one  inch  above  the  sym- 
physis, and  the  bladder  incised  in  a  direction  downward,  toward  the 
symphysis.  When  the  bladder  is  opened  the  fluid  contained  within 
it  escapes  in  part.  The  incision  should  be  large  enough  to  permit 
the  introduction  of  one  or  two  fingers  for  the  purpose  of  exploration, 
etc. 

The  incision  in  the  bladder  may  be  enlarged  sufficiently  to  allow 
necessary  manipulation;  caution  should  be  exercised  in  extending  the 
opening  in  the  bladder,  for  any  considerable  distance,  in  an  upward 
direction,  toward  the  umbilicus  (fold  of  peritoneum). 

If  a  stone  is  present,  it  may  be  removed  with  the  forceps,  guided 
by  the  finger;  if  the  stone  is  very  large,  it  may  first  be  crushed.  One 
should  search  the  bladder  carefully  for  stones  which  have  become 
almost  completely  encysted  in  pockets  in  the  bladder  wall.  If  the 
operation  is  done  for  ulcer  of  the  bladder,  the  diseased  area  may  be 
scraped  or  cauterized,  etc.  With  the  patient  in  the  Trendelenburg 
position  and  the  edges  of  the  wound  drawn  asunder  with  broad  re- 
tractors, the  interior  of  the  bladder  may  be  illuminated  and  made 
visible;  an  hypertrophied  prostate  may  be  enucleated  through  the 
suprapubic  opening. 

After  the  work  within  the  bladder  has  been  completed,  the  open- 
ing may  be  closed  with  a  line  of  sutures.  They  should  bring  the  edges 
of  the  opening  in  the  bladder  into  accurate  apposition,  and  should 
pass  through  all  the  layers  of  the  wall  of  the  bladder  down  to,  but 
not  including,  the  mucous  membrane.  None  of  the  sutures  should 
pass  through  the  whole  thickness  of  the  wall  of  the  bladder.  Fine 
silk  or  catgut  may  be  used. 

If  the  opening  in  the  bladder  wall  is  closed,  the  incision  in  the 
wall  of  the  abdomen  should  be  left  open,  at  least  in  part,  and  packed, 
in  order  to  provide  drainage;  it  will  also  be  necessary  to  leave  a  cath- 
eter in  the  urethra  for  several  days.  In  most  cases  it  is  probably  wise 
to  leave  the  incision  in  the  bladder  unclosed,  stitching  the  margins  of 
the  opening  in  the  bladder  to  the  edges  of  the  muscles  in  the  abdom- 
inal wound  with  two  or  three  interrupted  silk  sutures  on  either  side, 
their  ends  being  left  long  to  facilitate  their  removal  later.  There 
are  introduced  through  the  suprapubic  opening  into  the  bladder  two 
drainage  tubes.  One  of  the  tubes  is  long,  and  reaches  from  the  bottom 
of  the  bladder  over  the  side  of  the  bed  into  a  bottle  partly  filled  with 
an  antiseptic  solution  and  suspended  from  the  side  of  the  bed.  The 
second  tube,  which  is  short,  is  for  the  purpose  of  assisting  siphonage 


SURGICAL  ANATOMY  OF  THE  PENIS.  481 

of  the  bladder  and  to  facilitate  irrigation.  These  tubes  are  fixed  in 
the  bladder  by  passing  the  silk  tractor  stitches  (which  were  introduced 
in  the  early  stage  of  the  operation)  through  the  tubes.  The  wound 
is  packed  loosely  about  the  tubes  with  iodoform  gauze. 

The  fistula  that  remains  after  the  tubes  are  removed  rapidly 
diminishes  in  size,  and  finally  closes  spontaneously,  provided  the  ure- 
thral canal  is  unobstructed.  In  many  cases  it  will  suffice  to  fix  the 
tubes  in  the  bladder  with  the  silk  tractor  sutures,  omitting  the  sutur- 
ing of  the  edges  of  the  opening  in  the  bladder  to  the  abdominal  inci- 
sion. 

Puncture  of  the  Bladder  may  be  made  in  the  middle  line  just 
above  the  symphysis,  or  through  the  rectum.  It  is  done  for  the  pur- 
pose of  drawing  off  the  urine  when  the  patient  is  unable  to  empty  the 
bladder  through  the  urethra.  One  should  first  satisfy  himself  by  per- 
cussion, etc.,  that  the  bladder  is  actually  distended. 

A  medium-sized  curved  trochar  is  introduced  above  the  symphy- 
sis; it  should  be  thrust  through  the  anterior  abdominal  wall  in  the 
middle  line  just  above  the  symphysis,  and  in  a  direction  backward  and 
downward,  toward  the  sacrum,  for  a  distance  of  two  or  three  inches. 

If  introduced  through  the  rectum,  the  trochar  should  be  guided 
upon  the  finger  into  the  rectum  beyond  the  base  of  the  prostate,  at 
which  point  it  is  thrust  into  the  bladder  in  a  direction  upward  and 
forward,  toward  the  symphysis.  The  suprapubic  route  is  probably 
preferable. 

THE  PENIS. 

Surgical  Anatomy  of  the  Penis. — The  penis  when  erect  is  pris- 
moid  in  shape.  It  is  composed  of  the  corpora  cavernosa  and  the 
corpus  spongiosum. 

The  corpora  cavernosa  are  two  cylinders  of  erectile  tissue  which 
run  parallel  with  each  other  and  occupy  the  upper  part  of  the  organ. 
They  consist  of  a  mesh-work  of  vascular  spaces,  which  may  readily 
become  distended  with  blood,  thus  bringing  the  penis  into  a  con- 
dition of  erection.  They  are  each  provided  with  a  strong,  fibrous 
envelope,  the  tunica  albuginea,  and  behind  diverge,  to  be  attached 
to  the  rami  of  the  pubes. 

The  corpus  spongiosum  is  situated  below  the  corpora  cavernosa, 
and  contains  the  urethral  canal,  which  is  also  surrounded  by  cavern- 
ous, or  erectile,  tissue. 

The  end  of  the  penis  is  enlarged,  rather  bulbous,  and  is  known 


482  URINARY  SYSTEM. 

as  the  glans;  this  is  really  the  enlarged  extremity  of  the  corpus 
spongiosum.  Behind,  in  the  perineum,  the  corpus  spongiosum  is 
enlarged  and  forms  the  bulb.  The  penis  at  its  root  is  firmly  con- 
nected to  the  symphysis  by  a  fibrous  band,  the  suspensory  ligament. 

The  three  cylinders  which  together  form  the  penis  are  bound 
together  by  a  fibrous  sheath,  and  covered  with  a  soft,  loose,  movable 
envelope  of  skin,  which,  at  the  extremity,  is  reflected  over  the  glans 
for  a  greater  or  less  distance,  forming  the  prepuce.  The  constriction 
behind  the  glans  is  called  the  corona. 

Passing  forward  along  the  dorsal  surface  of  the  penis,  in  the 
groove  between  the  corpora  cavernosa,  are  two  arteries,  one  on  each 
side,  the  dorsal  arteries  of  the  penis,  branches  of  the  internal  pudic, 
and  lying  between  the  two  arteries  is  the  single  dorsal  vein. 

OPERATIONS  UPON  THE  PENIS. 

Forcible  Dilatation  of  the  Prepuce  for  Phimosis. — This  may  be 
practiced  in  many  cases,  especially  in  newborn  and  young  children, 
instead  of  a  dorsal  section  or  circumcision.  An  anaesthetic  is  unnec- 
essary. The  skin  of  the  prepuce  is  seized  and  peeled  forcibly  back- 
ward over  the  glans  as  far  as  the  corona.  This  is  readily  done  in 
most  cases,  even  when  the  orifice  of  the  prepuce  is  quite  narrow. 
The  margin  of  the  prepuce  stretches  and  suffers  slight  tears  here 
and  there  about  its  circumference;  it  should  be  drawn  back  and 
forth  several  times,  and  again  repeated  daily  for  several  days.  When 
the  prepuce  is  drawn  back,  any  hardened  smegma  that  has  accumu- 
lated should  be  removed,  and  the  glans  washed  and  smeared  with 
oil  or  vaselin;  the  skin  is  then  again  drawn  forward  over  the  glans, 
since  the  constriction  of  the  narrow  prepuce  might  cause  some  incon- 
venience if  allowed  to  remain  back  behind  the  glans.  After  the  fore- 
skin has  been  drawn  back  and  forth  over  the  glans  a  dilator  may  be 
introduced  into  its  orifice,  and  it  may  then  be  forcibly  and  thoroughly 
dilated.    In  most  cases  this  is  unnecessary. 

Dorsal  Section. — This  operation  is  done  for  phimosis  in  the 
young,  when  one  is  unable  to  retract  the  skin  and  when  it  is  not 
desirable  to  do  a  complete  circumcision,  and  in  adults  in  all  cases 
where  it  is  necessary  to  expose  the  glans  for  treatment. 

The  skin  of  the  penis  is  rolled  slightly  back  toward  the  root  of 
the  organ  with  the  finger  and  thumb,  and  one  blade  of  a  blunt- 
pointed  scissors  introduced  beneath  the  prepuce,  between  it  and  the 


OPERATIONS  UPON  THE  PENIS. 


483 


glans,  as  far  back  as  the  corona,  and  the  foreskin  then  divided  along 
the  middle  line,  steadying  it  so  that  it  will  not  roll  or  slip.  The 
scissors  should  be  sharp,  especially  toward  the  ends. 

The  prepuce  should  not  be  divided  for  its  whole  length,  but  only 
to  within  a  short  distance  of  the  corona. 

One  should  be  careful  not  to  introduce  the  blade  of  the  scissors 
into  the  urethral  canal  instead  of  between  the  glans  and  prepuce; 
this  might  happen  if  the  prepuce  were  intimately  adherent  to  the 
surface  of  the  glans,  as  is  sometimes  the  case. 

Instead  of  using  the  scissors  the  section  may  be  made  with  a 
sharp-pointed,   curved  bistoury,   guided  upon  a  grooved   director, 


Fig.  211. — Dorsal  Section  (Roser).  Prepuce  has  been  divided  upon  the 
dorsal  aspect.  M,  edge  of  incised  mucous  membrane;  S,  edge  of  skin.  Dotted 
lines  indicate  little  triangular  flap  (F)  of  mucous  membrane  that  is  cut  from 
the  mucous  to  the  skin  edge  of  the  divided  prepuce.  The  flap  is  turned  back 
and  sutured  into  the  angle  of  the  wound;  the  edge  of  mucous  membrane  and 
skin  may  also  be  joined  on  each  side  with  one  or  two  stitches. 


which  is  introduced  underneath  the  prepuce,  between  it  and  the 
glans.    As  a  rule,  there  is  but  little  hemorrhage. 

If  the  parts  are  not  infected,  one  or  two  catgut  stitches  may  be 
introduced  on  either  side.  Usually  no  suture  is  necessary  in  the 
child. 

Eoser's  Method  of  Dorsal  Section. — After  the  dorsal  section 
has  been  made,  the  mucous  membrane  not  being  cut  as  far  back  as 
the  skin,  an  oblique  incision  is  made,  on  either  side,  from  the  corner 
of  the  mucous  membrane  backward  and  outward  as  far  as  the  edge  of 
the  skin.  The  little  triangular  mucous  membrane  flap  which  is  thus 
formed  is  then  turned  up  into  the  angle  in  the  skin,  to  insure  rapid 


484  URINARY  SYSTEM. 

healing  in  the  corner  of  the  incision;  it  may  be  held  in  place  with  one 
stitch  in  the  angle  of  the  incision.  One  or  two  stitches  may  also  be 
introduced,  on  either  side  of  the  incision  proper. 

Circumcision. — In  children  an  anaesthetic  is  necessary;  in  adults 
the  operation  may  be  done  under  the  influence  of  cocain,  which  is 
injected  into  the  prepuce  after  a  strip  of  gauze  has  been  tied  fairly 
tight  about  the  body  of  the  penis  near  its  root  to  prevent  diffusion 
of  the  cocain.  One  should  avoid  cutting  the  skin  too  short.  After 
the  parts  have  healed  there  should  be  a  little  redundancy  of  the  skin 
marking  the  previous  reflection  of  the  prepuce,  and  this  is  best  ac- 
complished by  drawing  the  skin  a  little  backward,  toward  the  root 
of  the  penis,  before  applying  the  constricting  band.     The  first  step 


Fig.  212.— Circumcision.  Dorsal  section  has  been  made.  The  corners  of 
the  divided  prepuce  are  grasped  with  artery  forceps  preparatory  to  trimming 
it  away  with  the  scissors. 

in  the  operation  is  the  dorsal  section  of  the  prepuce.  One  blade  of 
a  scissors  is  introduced  underneath  the  prepuce  to  a  point  just  in 
front  of  the  corona,  and  the  prepuce  then  divided  to  within  a  short 
distance  of  the  corona.  Either  corner  of  the  divided  prepuce  is  seized 
with  an  artery  clamp  close  to  the  edge  of  the  incision,  and  with  a 
straight,  blunt-pointed  scissors  the  redundant  portion  of  the  prepuce 
is  trimmed  off,  first  around  one  side  and  then  around  the  other  as 
far  as  the  attachment  of  the  fraenum,  and  finally  cut  through  in  this 
situation,  just  in  front  of  the  fraenum  and  without  dividing  the  frae- 
num. 

The  entire  length  of  the  prepuce  should  not  be  amputated; 
about  one-fourth  its  length  should  remain. 


OPERATIONS  UPON  THE  PEXIS.  485 

As  a  rule,  the  bleeding  stops  when  the  ligature  around  the  penis 
is  removed  and  after  a  few  minutes'  compression.  Bleeding  arterial 
points,  however,  should  he  seized  with  a  clamp  and  twisted.  All 
bleeding  should  be  checked  before  suturing,  if  necessary  applying 
fine  catgut  ligatures. 

The  edges  of  the  skin  and  mucous  membrane  are  united  with 
interrupted  catgut  sutures,  the  first  being  applied  in  the  middle  line 
above,  the  next  in  the  middle  line  below,  then  one  on  each  side,  and 
finally  in  the  intervals  between  these,  making  eight  sutures  in  all. 

In  the  child,  as  a  rule,  the  four  sutures  are  sufficient. 

Circumcision  with  the  Clamp. — After  the  parts  have  been  anaes- 
thetized, etc.,  the  edge  of  the  prepuce  is  seized  above  in  the  middle 
line  and  below  in  the  middle  line  with  artery  forceps,  and  drawn 
forcibly  forward  over  the  glans.  That  part  of  the  prepuce  which 
is  thus  pulled  beyond  the  glans  is  grasped  between  the  blades  of  a 
long,  straight  clamp,  which  is  applied  obliquely  from  above  downward 
and  forward;  the  clamp  should  seize  the  foreskin  firmly,  and  care 
should  be  observed  that  the  glans  is  not  included;  this  accident,  how- 
ever, is  not  likely  to  occur. 

That  part  of  the  prepuce  which  protrudes  beyond  the  blades  of 
the  clamp  is  trimmed  off  with  a  sharp  knife  or  with  the  scissors  plane 
with  the  surface  of  the  clamp,  and  the  clamp  then  removed.  The 
hemorrhage  is  controlled  and  the  sutures  applied  as  above. 

Amputation  of  the  Penis. — This  operation  is  done  for  malignant 
disease.  A  sound  is  passed  into  the  urethra,  and,  supported  upon 
this,  the  penis  is  lifted  away  from  the  body.  An  elastic  ligature  is 
placed  about  the  organ  close  to  its  root. 

A  circular  incision  is  made  through  the  integument  and  a  flap 
reflected  sufficiently  long  to  cover  over  the  stump  of  the  penis;  it 
should  be  equal  in  length  to  half  the  diameter  of  the  penis  plus  one- 
third  for  shrinkage.  After  the  flap  has  been  turned  back  like  a  cuff 
the  portion  of  the  penis  that  is  to  be  amputated  is  cut  away.  The 
urethral  portion  of  the  penis  should  be  cut  about  one-fourth  inch 
longer  than  the  part  that  corresponds  to  the  corpora  cavernosa. 

The  blade  of  the  scalpel  is  thrust  flatwise  through  the  penis 
between  the  urethral  portion,  which  may  be  recognized  by  the  sound 
within,  and  the  corpora  cavernosa,  and  carried  a  good  one-fourth 
inch  forward  toward  the  glans,  when  the  urethral  portion  is  cut 
through  with  a  circular  sweep  of  the  knife  down  upon  the  sound 
contained  within.     The  corpora  cavernosa  are  then  divided  upon  a 


486 


URINARY  SYSTEM. 


plane  farther  back,  corresponding  to  the  base  of  the  skin  flap,  so  that 
the  urethral  portion  will  project  about  one-fourth  inch  beyond  the 
cut  surface  of  the  corpora  cavernosa. 

The  tourniquet  is  now  removed  from  the  root  of  the  penis.  The 
dorsal  arteries  bleed,  and  require  to  be  clamped  and  ligated.  The 
arteries  of  the  corpora  cavernosa  usually  require  no  ligatures;  if  they 


Fig.  213.— Amputation  of  the  Penis.    CG,  corpora  cavernosa;    F,  skin  flap 
turned   back;     U,   urethral   portion   cut  long. 

spurt,  they  may  be  clamped  or  touched  with  the  Paquelin.  A  few 
minutes'  compression  usually  suffices  to  check  bleeding  from  any  re- 
maining sources. 

The  edges  of  the  urethra  are  seized  with  two  artery  clamps,  and 
the  urethra  then  split  upon  its  under  aspect  for  a  distance  of  about 
one-fourth  inch.     The  skin  flaps  are  turned  over  the  end  of  the 


Fig.  214. — Amputation  of  the  Penis.  Edges  of  skin  flap  united  to  each 
other  over  the  ends  of  the  corpora  cavernosa  and  to  the  edges  of  the  split 
urethral  portion. 

stump,  and  are  united  from  before  backward  with  several  inter- 
rupted sutures,  and  the  edges  of  the  split  urethral  orifice  are  sewed 
to  the  adjoining  edges  of  the  skin  flaps. 

The  object  of  cutting  the  urethra  long  and  splitting  it  is  to 
provide  a  larger  orifice  to  allow  for  subsequent  contraction. 

A  soft  rubber  catheter  is  introduced  into  the  bladder  and  al- 


PERINEUM  AND  ISCHIORECTAL  REGION.  487 

lowed  to  remain  for  several  days,  its  end  emerging  through  the 
dressings.  It  may  be  fixed  with  a  silk  stitch  to  the  edge  of  the  urethral 
orifice. 

THE  PERINEUM  AND  ISCHIORECTAL  REGION. 

The  Floor  of  the  Pelvis  from  "Without  Inward.  —  This  space  is 
lozenge-shaped;  its  front  portion  is  limited  on  either  side  by  the 
rami  of  the  pubes  and  ischium;  its  posterior  part  is  limited  on  either 
side  by  the  edges  of  the  great  sacro-sciatic  ligaments.  The  anterior 
angle  corresponds  to  the  symphysis  pubis,  the  posterior  angle  to  the 
tip  of  the  coccyx,  and  on  either  side  the  tuber  ischii  may  be  felt. 
There  is  a  more  or  less  complete  fibrous  raphe  running  from  before 
backward  in  the  middle  line,  and  also  one  from  side  to  side  where 
all  the  layers  of  the  perineal  fascia  are  blended  together.  Where  these 
lines  intersect  there  is  a  point  where  muscles  are  attached  and  take 
origin  and  where  all  the  fascia?  are  joined.  This  is  known  as  the  cen- 
tral tendinous  point  of  the  perineum.  The  space  in  front  of  the  trans- 
verse raphe  is  the  perineum  proper;  the  space  behind  it  is  occupied 
by  the  anus  and  upon  either  side  by  the  ischio-rectal  fossa,  and  is 
known  as  the  ischio-rectal  region. 

The  Superficial  Layer  of  the  Superficial  Perineal 
Fascia. — Beneath  the  skin  there  is  a  layer  of  loose  fascia  which  is 
continuous  with  the  superficial  fascia  of  the  thighs  and  buttocks. 
This  is  the  superficial  layer  of  the  superficial  fascia  of  the  perineum 
and  ischio-rectal  regions;  it  corresponds  to  the  subcutaneous  fat,  and 
is  continuous  in  front  with  the  dartos  layer  of  the  scrotum,  and  be- 
hind, upon  either  side  of  the  anus,  it  is  packed  into  the  ischio-rectal 
fossa  as~a  pyramidal  plug  of  fat  and  loose  connective  tissue. 

The  Deep  Layer  of  Superficial  Perineal  Fascia. — If  we 
remove  this  superficial  layer  of  fascia  and  fat,  including  the  mass 
from  the  ischio-rectal  fossa,  we  come  down  upon  a  second  layer  of 
fascia,  the  deep  layer  of  the  superficial  fascia  of  the  perineum.  Cor- 
responding to  the  perineal  region  proper,  the  fascia  is  attached  upon 
each  side  to  the  edge  of  the  pubic  arch  and  behind  to  the  transverse 
raphe;  in  front  it  is  continuous  with  the  dartos  of  the  scrotum;  be- 
hind, in  the  ischio-rectal  region,  it  is  continuous  with  the  anal  fascia, 
which  covers  the  perineal  surface  of  the  levator  ani  muscles. 

Anteriorly  this  fascia  is  dense,  and  serves  to  close  in  the  struct- 
ures proper  to  the  perineum.  If  fluid  is  injected  underneath  this 
layer  of  fascia,  it  will  not  spread  backward  beyond  the  transverse 


488  URINARY  SYSTEM. 

raphe,  because  this  layer  of  fascia  is  attached  along  this  raphe  with 
the  next  underlying  fascial  layer;  it  will  not  escape  laterally,  owing 
to  the  attachment  of  the  fascia  to  the  margins  of  the  bony  pelvic 
arch;  but  anteriorly  it  will  escape,  passing  into  the  dartos  tissue  of 
the  scrotum  and  thence  upward  upon  the  front  of  the  pubes. 

The  Ischio-rectal  Region. — This  is  the  region  which  lies  behind 
the  transverse  raphe — that  part  which  corresponds  to  the  anus  and 
the  ischio-rectal  fossa. 

In  the  middle  is  the  anus,  surrounded  by  its  external  sphincter 
muscle.  This  muscle  arises  from  the  tip  of  the  coccyx  behind,  and, 
passing  forward,  is  attached,  in  front  of  the  anus,  to  the  middle 
tendinous  point  of  the  perineum,  which  corresponds  to  the  junction 
of  the  sphincter  from  behind,  the  transversus  perinei  from  each  side, 
and  the  bulbo-cavernosus  from  in  front. 

On  either  side  of  the  anus  there  is  a  pyramidal  space,  the  ischio- 
rectal fossa;  this  space  is  occupied  by  a  mass  of  fat  and  loose  con- 
nective tissue,  the  base  of  which  corresponds  to  the  superficial  layer 
of  superficial  perineal  fascia,  and  reaches  from  the  tuberosity  of  the 
ischium  to  the  anus.  This  space  is  about  two  inches  deep.  Its  outer 
wall  is  formed  by  the  tuber  ischii  and  the  obturator  internus  muscle, 
which  muscle  is  covered  over  by  a  layer  of  fascia,  the  obturator  fascia. 
Passing  forward  upon  this  outer  wall  of  the  ischio-rectal  fossa,  be- 
neath the  obturator  fascia  and  about  one  and  one-half  inches  above 
the  tuberosity  of  the  ischium,  are  the  internal  pudic  vessels  and 
nerve. 

The  inner  wall  of  the  ischio-rectal  space  is  formed  by  the  levator 
ani  (to  be  described  later).  The  superficial  surface  of  this  muscle, 
which  looks  into  the  ischio-rectal  space,  is  covered  by  the  anal  fascia, 
which  is  derived  from  the  obturator  fascia  along  the  line  of  the 
origin  of  the  levator  ani  from  the  side  of  the  pelvis.  This  anal 
fascia  is  attached  in  front  to  the  transverse  fibrous  raphe  and  is 
continuous  there  with  the  deep  layer  of  the  superficial  perineal  fascia. 

The  ischio-rectal  space  is  thus  walled  off  from  the  perineal  space 
proper  and  from  the  rectum.  It  is  the  seat  of  the  so-called  ischio- 
rectal abscess,  and  when  this  breaks  through  into  the  rectum  it  forms 
the  fistula  in  ano. 

Some  small  vessels  and  nerve  branches  cross  this  space  trans- 
versely just  beneath  the  skin,  passing  from  the  tuberosity  of  the 
ischium  toward  the  anus,  and  these  are  cut  when  incisions  are  made 
into  the  space. 


PERINEUM  AND  ISCHIORECTAL  REGION.  489 

The  Perineum. — Upon  removing  the  deep  layer  of  superficial  peri- 
neal fascia  we  open  into  the  proper  perineal  space. 

Occupying  the  middle  of  the  space  is  a  thin  muscle,  the  bulbo- 
cavernosus;  it  arises  from  the  middle  tendinous  point  of  the  peri- 
neum, and,  passing  forward,  covers  the  bulb  of  the  urethra,  which  is 
the  posterior  enlarged  portion  of  the  corpus  spongiosum,  joining, 


Fig.  215.— The  Perineum  and  Ischio-rectal  Region.  The  superficial  and 
deep  layers  of  the  superficial  perineal  fascia  have  been  removed.  The  space 
in  front  of  the  transversus  perinei  (TP)  corresponds  to  the  perineum;  that 
behind  the  transversus  perinei  to  the  ischio-rectal  region.  The  floor  of  the 
space  (TL)  corresponds  to  the  anterior  layer  of  the  triangular  ligament.  BO, 
bulbo-cavernosus  muscle;  C,  tip  of  coccyx;  CC,  corpus  cavernosum  (crus 
penis) ;  CS,  corpus  spongiosum  (the  posterior  part  of  the  corpus  spongiosum 
is  called  the  bulb  of  the  urethra);  G,  edge  of  gluteus  maximus  muscle;  IG, 
ischio-cavernosus  muscle;  LA,  levator  ani  muscle;  R,  ramus  of  the  pubes 
and  ischium;  8  A,  sphincter  ani;  8L,  edge  of  great  sacro-sciatic  ligament; 
'l'I,  tuberosity  of  the  ischium;  TL,  superficial  or  anterior  layer  of  the  tri- 
angular ligament;  TP,  transversus  perinei  muscle. 


with  fibers  from  the  muscle  of  the  opposite  side  upon  its  upper  sur- 
face, in  a  strong  aponeurosis.  The  most  anterior  fibers  of  the  bulbo- 
cavernosus  muscle  are  attached  on  either  side  to  the  crus  penis,  some 
entirely  encircling  these  bodies  and  joining  upon  the  upper  surface 
of  the  root  of  the  penis  in  such  a  way  as  to  bind  down  the  dorsal 
vessels  of  the  penis,  obstructing  the  return  flow  through  the  vein. 


490  URINARY  SYSTEM. 

This  muscle  shows  a  median  fibrous  raphe.  Upon  either  side,  arising 
from  the  ascending  ramus  of  the  ischium,  is  the  ischio-cavernosus. 
The  fibers  of  this  muscle  partly  cover  the  crus  penis,  and  are  attached 
to  its  sheath.  The  crus  penis  is  the  posterior  portion  of  the  corpus 
cavernosum,  and  is  attached  to  the  ramus  of  the  ischium  and  pubes. 

Forming  the  posterior  border  of  this  space  on  either  side  is  the 
transversus  perinei  muscle.  This  muscle  arises  from  the  inner  surface 
of  the  tuberosity  of  the  ischium;  it  passes  inward  and  forward  to  the 
central  tendinous  point  of  the  perineum,  where  it  is  attached,  joining 
with  the  muscle  of  the  opposite  side  and  the  other  muscles  already 
described. 

Passing  forward  through  this  space  are  the  superficial  perineal 
vessels  and  nerve,  and  directed  inward  along  the  border  of  the  trans- 
versus perinei  is  the  transverse  perineal  artery. 

The  floor  of  this  space  is  formed  by  a  dense  layer  of  fascia,  the 
superficial  layer  of  the  deep  perineal  fascia,  or,  better,  of  the  triangular 
ligament.  This  layer  of  fascia  is  perforated  by  the  urethral  canal 
about  one  and  one-half  inches  below  the  symphysis.  Beneath  this 
layer  of  fascia  there  is  a  second  layer,  similar  in  structure,  the  deep 
layer  of  the  deep  perineal  fascia  or  triangular  ligament. 

Behind,  corresponding  to  the  transverse  perineal  raphe,  these 
two  layers  of  deep  fascia  are  blended  with  each  other  and  with  the 
deep  layer  of  the  superficial  perineal  fascia.  They  are  attached  later- 
ally to  the  inner  surface  of  the  rami  of  the  pubes  and  ischium;  above, 
in  front,  they  do  not  reach  to  the  symphysis,  but  terminate  in  the 
ligamentum  transversum  pelvis,  a  ligamentous  band  passing  between 
both  pubic  rami,  leaving  a  space  above,  between  it  and  the  symphysis, 
for  the  passage  of  the  vena  dorsalis  penis. 

Between  the  two  layers  of  the  triangular  ligament  the  deep  trans- 
verse perineal  muscle,  the  compressor  urethra?,  is  located;  this  mus- 
cle is  made  up  chiefly  of  striped  muscular  fibers  passing  across  from 
one  pubic  ramus  to  the  other  above  and  below  the  urethra,  and  also 
of  unstriped  fibers  which  pass  in  various  directions,  some  encircling 
the  membranous  part  of  the  urethra. 

The  two  layers  of  the  triangular  ligament,  together  with  the 
muscle  contained  between  them,  form  the  uro-genital  diaphragm.  In 
the  space  between  the  two  layers  of  the  triangular  ligament,  besides 
the  muscle,  are  contained  the  urethra,  its  membranous  portion,  and 
behind,  on  either  side,  Cowper's  gland,  the  duet  of  which  is  seen 
passing  forward  to  enter  the  bulbous  portion  of  the  urethra.    Poste- 


PERINEUM  AND  ISCHIORECTAL  REGION.  491 

riorly,  close  to  the  lateral  border  of  the  space,  is  seen  the  internal 
pudic  artery.  It  gives  off  the  artery  of  the  bulb,  and  passing  forward 
divides  into  the  artery  of  the  cms  penis,  which  enters  the  cms,  and 
the  dorsal  artery  of  the  penis,  which  perforates  the  suspensory  liga- 
ment and  runs  forward  along  the  upper  surface  of  the  penis. 

As  the  urethra  perforates  the  superficial  layer  of  the  triangular 
ligament  it  is  provided  with  a  fibrous  prolongation,  which  is  con- 
tinued forward  upon  the  bulb  of  the  urethra. 

The  posterior  or  deep  layer  of  the  triangular  ligament  is  con- 
tinous  (within  the  pelvis)  with  the  fascia  which  covers  the  obturator 
internus  muscle  and  the  upper  or  pelvic  surface  of  the  levator  ani 
muscle,  and  at  the  side  of  the  prostate  it  is  reflected  upward  upon 
this  gland. 

The  prostate  gland,  which  encircles  the  neck  of  the  bladder  and 
contains  the  prostatic  portion  of  the  urethra,  rests  upon  the  upper, 
or  pelvic,  surface  of  the  triangular  ligament  and  the  levator  ani. 

The  levator  ani  serves  to  close  in  that  part  of  the  pelvic  outlet 
which  lies  posterior  to  the  triangular  ligament.  The  anterior  fibers 
of  the  muscle  unite  in  the  middle  line  with  those  of  the  opposite  side 
in  a  sling-like  fashion  to  support  the  prostate.  The  fibers  more  poste- 
riorly are  continued  into  either  side  of  the  rectum  and  to  the  tip  of 
the  coccyx. 

The  seminal  vesicles  and  the  vas  deferens  lie  within  the  pelvis, 
between  the  second  part  of  the  rectum  and  the  base,  or  trigone,  of  the 
bladder,  above  the  upper  border,  or  base,  of  the  prostate.  They  may 
be  brought  into  view  by  separating  the  rectum  from  the  base  of  the 
bladder  and  drawing  it  backward  toward  the  coccyx. 

The  Pelvic  Cavity  from  Within.  —  Examining  the  pelvic  cavity 
from  within,  after  removal  of  the  bladder  and  rectum,  we  find  it 
bounded  in  front  by  the  pubic  bones,  behind  by  the  coccyx  and  sa- 
crum, laterally  by  the  pubes  and  ischium  and  the  sacro-sciatic  liga- 
ments. The  lateral  wall  of  the  pelvic  cavity  is  partly  covered  by  the 
obturator  internus  muscle,  which  arises  from  the  inner  surface  of  the 
pubes  and  ischium  around  the  margin  of  the  obturator  foramen. 

The  obturator  internus  is  covered  by  a  thick  fascia,  which  is  at- 
tached above  to  the  margin  of  the  brim  of  the  pelvis,  being  continuous 
above  with  the  fascia  that  covers  the  psoas  and  iliacus  muscles  (the 
fascia  iliaca).  In  front  this  obturator  fascia  is  continued  into  the 
posterior  or  deep  layer  of  the  triangular  ligament. 

The  obturator  fascia  is  marked  by  a  thick,  white,  fibrous  band, 


492  URINARY  SYSTEM. 

which  extends  along  the  lateral  wall  of  the  pelvis  from  before  back- 
ward, from  the  posterior  surface  of  the  pubic  bone  in  front  to  the 
spine  of  the  ischium  behind,  and  is  known  as  the  tendo  arcuatum. 
Along  this  line  upon  either  side  of  the  pelvis  the  levator  ani  takes  its 
origin.  The  muscles  pass  in  a  general  direction  obliquely  downward 
and  inward,  joining  with  each  other  in  the  middle  line.  The  ante- 
rior fibers  pass  downward,  inward,  and  backward,  and  unite  in  the 
middle  line  underneath  the  prostate,  which  they  support  in  a  sling-like 
manner.  The  more  posterior  fibers  pass  downward  and  inward,  and 
are  inserted  into  the  sides  of  the  rectum  just  above  the  anus;  the 
fibers  behind  these  are  attached  to  the  tip  of  the  coccyx. 

Still  more  posteriorly  lies  the  coccygeus.  This  muscle  looks 
like  a  continuation  of  the  levator  ani,  and  serves  to  close  in  the  out- 
let of  the  pelvis  behind  the  levator  ani.  It  is  fan-shaped,  and  is 
attached  by  its  apex  to  the  spine  of  the  ischium  and  by  its  broad 
base  to  the  lateral  margin  of  the  coccyx. 

Lying  upon  the  same  plane,  but  still  farther  above  and  behind, 
and  corresponding  to  the  upper  border  of  the  coccygeus  muscle,  is 
the  pyriformis.  This  muscle  arises  from  the  sides  and  from  the  ante- 
rior surface  of  the  sacrum,  and  passing  outward  leaves  the  pelvis 
through  the  great  sacro-sciatic  notch,  and  closes  the  pelvic  cavity 
behind. 

Thus,  taking  part  in  the  formation  of  the  floor  of  the  pelvis, 
there  is  a  muscular  layer  which  is  formed  in  front  by  the  levatores 
ani,  behind  this  by  the  coccygei,  and  still  farther  behind  and  above 
by  the  pyrif ormi. 

In  the  front  part  of  the  floor  of  the  pelvis,  between  the  margins 
of  the  levatores  ani,  there  is  a  space  which  corresponds  to  the  poste- 
rior, or  deep,  layer  of  the  triangular  ligament. 

The  fascia  that  covers  the  obturator  muscle,  the  obturator 
fascia,  is  continuous  in  front  with  the  posterior,  or  deep,  layer  of  the 
triangular  ligament;  corresponding  to  the  line,  the  tendo  arcuatum, 
which  marks  the  origin  of  the  levator  ani,  this  obturator  fascia,  which 
is  simply  a  portion  of  the  general  pelvic  fascia,  gives  off  a  layer  that 
covers  the  pelvic  surface  of  the  levator  ani;  farther  back  the  pelvic 
surface  of  the  coccygeus  and  the  pyriformis  and  the  front  of  the 
sacrum  are  also  covered  by  a  continuation  of  this  same  fascia. 

Where  this  fascia,  after  covering  the  pelvic  surface  of  the  levator 
ani,  strikes  the  prostate  and  the  rectum,  it  is  reflected  upward  upon 
the  sides  of  these  organs. 


OPERATIONS  UPON  THE  PERINEUM,  ETC.  493 

A  process  of  this  fascia  is  reflected  inward  between  the  rectum 
and  the  base  of  the  bladder,  and  serves  to  bind  the  seminal  vesicles 
and  vas  deferens  to  the  base  of  the  bladder. 

The  nnder  surface  of  the  levator  ani,  which  is  directed  toward 
the  perineum  and  ischio-rectal  fossa,  is  also  covered  by  a  thin  layer 
of  fascia,  which  is  derived  from  the  obturator  fascia  along  the  line 
of  the  origin  of  the  levator  ani.    This  is  called  the  anal  fascia. 

The  anal  fascia  is  continued  backward  upon  the  under  surface 
of  the  coccygeus  muscle,  and  anteriorly  is  continued  forward  into  the 
deep  layer  of  the  superficial  perineal  fascia,  joining  along  the  trans- 
verse septum,  or  raphe,  with  all  the  other  fasciae  of  the  perineum. 

OPERATIONS  UPON  THE  PERINEUM,  ETC. 

Perineal  Section  (External  Urethrotomy)  With  a  Guide. — This 
operation  is  performed  for  stricture  of  the  deep  urethra  or  for  the 
purpose  of  draining  the  bladder.  The  patient  is  placed  in  the 
lithotomy  position  and  a  tunneled  sound  introduced  through  the 
urethra  into  the  bladder. 

An  assistant  steadies  the  sound  with  the  right  hand,  throwing 
the  groove  as  much  as  possible  toward  the  surface  of  the  perineum, 
and  at  the  same  time  drawing  the  whole  urethra  upward,  away  from 
the  rectum  toward  the  symphysis.  The  scrotum  is  drawn  up  toward 
the  symphysis,  out  of  the  way  of  the  operator. 

An  incision  is  made  in  the  middle  line  from  the  base  of  the 
scrotum  backward  to  within  a  short  distance  of  the  anus.  This  in- 
cision reaches  through  the  skin  and  fat  down  to  the  deep  layer  of 
the  superficial  perineal  fascia. 

The  edges  of  the  wound  are  drawn  asunder  with  small,  sharp 
retractors,  and  with  another  stroke  of  the  knife  the  deep  layer  of 
the  superficial  perineal  fascia  is  incised  and  the  bulb  of  the  urethra 
exposed  in  the  forward  part  of  the  wound.  Then,  with  the  finger 
in  the  wound,  the  groove  in  the  tunneled  guide  within  the  urethra 
is  recognized  and  the  point  of  the  knife,  guided  upon  the  finger-nail, 
is  placed  in  the  groove  of  the  sound,  piercing  the  membranous  part 
of  the  urethra  just  behind  the  bulb.  The  knife  is  then  shoved  back- 
ward, carrying  the  point  of  the  blade  along  the  groove  of  the  sound 
toward  the  neck  of  the  bladder  and  raising  the  handle,  at  the  same 
time,  toward  the  symphysis.  Having  carried  the  point  of  the  knife 
beyond  the  location  of  the  stricture  into  the  prostatic  portion  of  the 


494  URINARY  SYSTEM. 

urethra,  the  handle  is  depressed,  the  knife  at  the  same  time  being 
withdrawn  and  cutting  as  it  is  withdrawn;  in  this  way  the  mem- 
branous portion  of  the  urethra  is  laid  open  and  the  stricture  divided. 

While  the  urethra  is  being  incised  upon  the  grooved  sound  the 
sound  should  be  lifted  straight  up  toward  the  symphysis,  carrying 
the  urethra  with  it,  and  thus  drawing  it  farther  away  from  the 
rectum.  If  some  urine  or  fluid  is  in  the  bladder,  its  escape  will  demon- 
strate the  fact  that  the  bladder  has  been  entered. 

A  director  gorget  may  now  be  introduced  into  the  bladder  along 
the  groove  of  the  sound  and  the  latter  withdrawn.  A  soft  rubber 
catheter  of  large  caliber  is  introduced  through  the  opening  into  the 
bladder,  and  fixed  in  place  to  the  edge  of  the  incision  in  the  skin 
with  a  silk  stitch,  and  the  wound  then  packed. 

Usually  there  are  no  vessels  to  tie,  although  spurting  arterial 
branches  should  be  clamped  and  twisted  and,  if  necessary,  ligated. 
One  should  avoid  wounding  the  bulb  of  the  urethra  if  possible,  and, 
for  a  certainty,  the  rectum  and  anus. 

Before  dismissing  the  patient,  a  large  metal  sound,  at  least  a 
No.  30  F.,  should  be  passed  through  the  anterior  urethra  and  into 
the  bladder  to  make  certain  that  no  remaining  obstruction  exists  in 
any  part  of  the  canal. 

Perineal  Section  Without  a  Guide. — This  is  a  difficult  procedure. 

All  attempts  to  introduce  a  guide  through  the  constricted  part 
of  the  urethra  into  the  bladder  fail.  One  should  not  be  satisfied  with 
a  single  attempt,  but  should  try,  if  possible,  to  at  least  get  a  small 
whalebone  or  rubber  guide  through.  After  having  made  the  attempt 
and  found  it  impossible  to  get  any  guide  whatever  past  the  stricture, 
a  tunneled  sound  may  be  introduced  as  far  as  the  obstruction. 

As  described  in  the  preceding  operation,  an  incision  is  made  in 
the  perineum  and  the  urethral  canal  opened  upon  the  guide  just  in 
front  of  the  stricture.  After  all  the  bleeding  has  been  arrested,  the 
edges  of  the  wound,  including  the  edges  of  the  incised  urethra,  are 
retracted  with  small,  sharp  hooks,  and  an  effort  then  made  to  find 
the  opening  through  the  stricture  into  the  posterior  part  of  the  ure- 
thra by  inspection  or  by  attempting  to  pass  a  fine  probe-pointed 
director  or  a  fine  whalebone  guide.  At  times  pressure  upon  the 
bladder  will  force  a  few  drops  of  urine  through  the  orifice  of  the 
stricture,  and  this  may  assist  us  in  locating  it  (Koenig). 

If  we  do  not  succeed  in  getting  through  the  stricture  by  these 
means  an  effort  may  be  made  to  open  into  the  urethra  behind  the 


OPERATIONS  UPON  THE  PERINEUM,  ETC.  495 

stricture,  and  then,  if  this  is  successful,  the  stricture  may  be  divided 
from  behind.  It  is  difficult,  however,  to  locate  the  deep  urethra 
(membranous  portion)  without  a  guide.  It  lies  between  the  layers 
of  the  triangular  ligament,  reaching  from  the  bulbous  portion  of  the 
urethra  to  the  apex  of  the  prostate  gland.  Occasionally  the  urethra 
is  diverted  from  the  middle  line  or  a  false  passage  may  be  encount- 
ered which  will  still  further  confuse  us. 

At  times,  especially  if  the  bladder  contains  fluid  and  pressure  be 
made  above  the  pubes,  the  urethra  may  be  felt  as  a  rounded,  com- 
pressible tube,  occupying  the  middle  line  and  perforating  the  tri- 
angular ligament  about  one  and  one-half  inches  below  the  symphysis. 

The  prostatic  urethra,  which  is  the  continuation  of  the  mem- 
branous urethra,  is  surrounded  by  the  prostate  gland,  and,  if  one 
finger  is  introduced  into  the  rectum  and  the  thumb  placed  in  the 
incision  in  the  perineum  the  operator  may  get  the  prostate  between 
them,  and  the  apex  of  the  prostate  may  thus  serve  as  a  clue  to  the 
location  of  the  membranous  urethra.  One  should  refrain  from  blindly 
jabbing  in  the  wound  in  the  hope  of  accidentally  striking  the  urethra. 

If  all  these  measures  fail,  a  suprapubic  cystotomy  may  be  per- 
formed and  a  guide  passed  from  within  the  bladder  into  the  urethral 
canal,  in  this  way  locating  the  posterior  part  of  the  deep  urethra  for 
the  purpose  of  incision. 

If  it  becomes  necessary  to  do  a  suprapubic  cystotomy,  this  may 
be  more  conveniently  done  with  the  patient  in  the  Trendelenburg 
position.  A  suprapubic  cystotomy  under  these  circumstances  is  also 
a  difficult  procedure,  as  the  bladder  may  contain  little  or  no  urine 
and  may  therefore  lie  very  low  in  the  pelvis  behind  the  symphysis. 

Median  Lithotomy. — This  operation  is  performed  for  small  calculi. 
The  bladder  should  be  washed  out  with  boric-acid  solution,  5  or  6 
ounces  being  allowed  to  remain  in  the  bladder.  The  operation  is 
practically  the  same  as  the  preceding  perineal  section  (with  a  guide) 
except  that  the  incision  into  the  urethra  is  made  rather  more  ex- 
tensive, cutting  through  the  anterior  part  of  the  prostatic  as  well  as 
through  the  membranous  portion  of  the  urethra.  The  incision  should 
not  extend  entirely  through  the  prostate.  Oftentimes  after  the  blad- 
der has  been  opened  a  small  stone  will  of  itself  drop  out  of  the 
wound,  or  it  can  be  removed  with  forceps,  scoop,  etc.  It  may  be 
necessary  to  enlarge  the  internal  urethral  orifice  somewhat  with  a 
dilator  or  with  the  finger.  If  necessary,  a  larger  stone  may  be 
crushed  before  removal. 


496  URINARY  SYSTEM. 

The  finger  should  be  introduced  into  the  bladder  to  search  for 
partially  encysted  stones,  etc.  Finally  the  bladder  is  washed  out  and 
a  large,  rubber  catheter  introduced  through  the  perineal  wound  and 
fixed  to  the  edge  of  the  skin  with  a  silk  stitch.  The  wound  is  packed 
about  the  catheter  and  left  open. 

Lateral  Lithotomy. — The  bladder  is  washed  out  with  boric-acid 
solution,  4  or  5  ounces  being  left  remaining  in  the  bladder.  A  tun- 
neled sound  is  introduced  through  the  urethra  into  the  bladder  and 
steadied  by  an  assistant.  An  incision  is  made  through  the  skin  and 
fat,  commencing  in  front  at  the  base  of  the  scrotum  and  passing  back- 
ward and  outward  to  a  point  midway  between  the  tuberosity  of  the 
ischium  and  the  anus.  A  second  sweep  of  the  knife  incises  the  deep 
layer  of  the  superficial  perineal  fascia.  The  index  finger  of  the  left 
hand  is  then  introduced  into  the  wound,  and  the  finger-nail  placed  in 
the  groove  of  the  sound  in  the  front  part  of  the  wound,  just  behind 
the  bulb  of  the  urethra.  The  sound  is  then  drawn  upward  toward  the 
symphysis,  thus  lifting  the  whole  urethra  away  from  the  rectum,  and 
the  point  of  the  knife  placed  in  the  groove  of  the  sound,  cutting 
through  the  membranous  urethra.  The  handle  of  the  knife  is  then 
elevated  and  the  point  shoved  backward  along  the  groove  of  the  guide 
into  the  prostatic  urethra.  The  handle  of  the  knile  is  then  depressed, 
at  the  same  time  withdrawing  the  blade  and  cutting  as  it  is  with- 
drawn. In  this  way  the  membranous  urethra,  together  with  the  side 
of  the  prostate  itself,  are  incised,  the  division  of  these  deep  structures 
being  made  along  the  line  of  the  skin  incision. 

In  making  this  last  incision  upon  the  sound  the  superficial  trans- 
verse perineal  muscle,  and  the  artery  of  the  bulb,  together  with  the 
membranous  urethra,  the  prostate  gland,  and  the  triangular  ligament, 
are  cut.  It  is  usually  necessary  to  clamp  and  tie  the  artery  of  the  bulb, 
and  sometimes;  if  the  incision  extends  too  far  backward  and  outward, 
the  internal  pudic  may  be  divided;  this  branch  bleeds  profusely,  and 
must  be  tied.  After  the  bleeding  has  been  controlled  and  the  stone 
removed,  a  catheter  is  introduced  into  the  bladder  and  fixed  to  the 
edge  of  the  incision.  The  wound  is  packed  about  the  catheter  and 
left  unsutured. 

THE  PROSTATE. 

Surgical  Anatomy  of  the  Prostate. — The  prostate  is  a  glandular 
organ  about  the  size  and  shape  of  a  horse-chestnut.  It  is  lodged  in 
the  pelvic  cavity  behind  and  below  the  symphysis,  lying  close  to  the 


SURGICAL  ANATOMY  OF  THE  PROSTATE.  497 

neck  of  the  bladder  and  surrounding  the  commencement  of  the  urethra. 
It  is  situated  beneath  the  deep  perineal  fascia  (triangular  ligament) 
and  rests  upon  the  lower  part  of  the  rectum,  through  which  it  may- 
be readily  palpated,  especially  if  it  is  enlarged. 

The  prostate  measures  about  one  and  one-half  inches  in  its  trans- 
verse and  one  inch  in  its  antero-posterior  diameter  at  the  base  and 
is  three-fourths  of  an  inch  in  depth.  It  is  held  in  position  by  the 
anterior  ligaments  of  the  bladder  (pubo-prostatic)  and  by  the  poste- 
rior layer  of  the  deep  perineal  fascia  (triangular  ligament),  which  is 
reflected  upward  and  backward  around  the  gland  forming  its  external 
fibrous  sheath.  The  prostate  rests  upon  the  anterior  portions  of  the 
levatores  ani,  which  pass  downward  and  inward  from  their  origin  upon 
either  side  of  the  internal  aspect  of  the  symphysis  pubis  and  sides  of 
the  pelvis,  some  of  their  fibers  being  attached  to  the  sides  of  the  pros- 
tate and  others  joining  with  their  fellows  in  the  middle  line,  sling- 
like, underneath  the  prostate.  Those  portions  of  the  levatores  ani 
that  pass  underneath  and  support  the  prostate  are  sometimes  called 
the  levatores  prostatas. 

The  base  of  the  prostate  is  directed  backward  toward  the  neck 
of  the  bladder;  the  narrow  end,  apex,  is  directed  forward  and  down- 
ward toward  the  deep  perineal  fascia;  the  lower  surface  rests  upon 
the  lower  part  of  the  rectum,  from  which  it  is  separated  by  some  loose 
connective  tissue,  and  presents  a  deep  notch,  the  interlobular,  where 
the  ejaculatory  ducts  enter;  the  upper  surface  is  marked  by  a  slight 
longitudinal  furrow,  is  notched  anteriorly  and  posteriorly,  and  is  less 
than  one  inch  distant  from  the  symphysis  pubis. 

The  prostate  is  composed  of  glandular  and  unstriped  muscular 
tissue,  is  inclosed  within  its  own  proper  capsule,  and  is  made  up  of 
two  lateral  lobes  and  a  middle  portion,  sometimes  called  the  "middle 
lobe."  The  two  lateral  lobes  are  symmetrical  and  separated  behind, 
at  the  base,  by  the  interlobular  notch,  at  which  point  the  ejaculatory 
ducts  penetrate  the  organ.  The  middle  portion  corresponds  to  that 
part  of  the  base  of  the  gland  which  is  embraced  between  the  points 
where  the  urethra  and  the  ejaculatory  ducts  enter.  It  is  normally 
represented  by  a  small,  rounded  prominence  that  presents  immediately 
beneath  the  neck  of  the  bladder  and  just  behind  the  commencement 
of  the  urethra. 

The  prostate  is  traversed  by  the  urethra  and  ejaculatory  ducts. 

The  prostatic  portion  is  the  widest  and  most  dilatable  portion  of 
the  urethral  canal.    It  penetrates  the  entire  length  of  the  gland  from 


498 


URINARY  SYSTEM. 


base  to  apex,  and  is  situated  nearer  the  upper  than  the  lower  surface. 
The  prostatic  urethra  is  made  up  of  mucous  membrane  and  an  under- 
lying layer  of  connective  tissue  which  contains  unstriped  muscular 
fibers  and  elastic  tissue.  The  floor  of  the  prostatic  urethra  is  marked 
by  a  longitudinal  elevation,  nearly  one  inch  in  length,  the  verumont- 
anum.  At  the  anterior  end  of  the  verumontanum  is  the  mouth  of  the 
sinus  pocularis,  a  cul-de-sac  which  extends  backward  underneath  the 
verumontanum  for  about  one-fourth  inch.    Upon  or  near  the  margins 


Fig.  216. — Transverse  Section  of  Prostate  throu gh  the  Venimontanum. 
C,  capsule  of  gland;  D.,  ejaculatory  ducts ;  P.,  sinus  pocularis;  P.G.,  a 
prostatic  follicle  opening  upon  floor  of  urethra  ;  S.,  outside  fibrous  sheath 
of  prostate  gland ;  U.,  urethra.  In  the  space  between  the  capsule  and 
outside  fibrous  sheath  the  veins  of  the  pro  tatic  plexus  are  seen  on  section. 


of  the  mouth  of  the  sinus  pocularis  are  the  narrow,  slit-like  orifices 
of  the  ejaculatory  ducts.  The  floor  of  the  prostatic  urethra  presents 
upon  either  side  of  the  verumontanum  the  orifices  of  the  ducts  of  the 
prostatic  follicles,  from  twenty  to  thirty  in  number. 

Above  and  behind  the  prostate  body,  closely  applied  to  the  base 
of  the  bladder,  between  it  and  the  rectum,  are  the  vesiculas  seminales 
and  vasa  deferentia.  Each  vas  has  a  vesicula  seminalis  lying  to  its 
outer  side.  The  vasa,  as  they  pass  forward  toward  the  base  of  the 
prostate,  approach  each  other  and  just  before  they  enter  the  prostate 
they  join  with  the  ducts  of  the  corresponding  vesiculas  seminales  to 


OPERATIONS  UPON  THE  PROSTATE.  499 

form  the  common  ejaculatory  ducts.  The  common  ejaculatory  ducts, 
thus  formed,  pierce  the  prostate,  side  by  side  and  close  together,  at 
the  deep  interlobular  notch  that  marks  the  under  part  of  the  base  of 
the  gland.  They  pass  forward  through  the  prostate,  being  situated 
just  beneath  the  urethral  canal,  one  on  either  side  of  the  middle  line, 
and  empty  upon  the  floor  of  the  prostatic  urethra  close  to,  or  just 
within,  the  margins  of  the  sinus  pocularis. 

The  prostate  gland  is  inclosed  in  its  own  fibrous  capsule,  the 
capsule  proper,  which  is  composed  of  condensed  connective  tissue 
and  is  separate  and  distinct  from  the  fibrous  sheath  or  envelope  that 
is  reflected  around  it  from  the  posterior  layer  of  the  deep  perineal 
fascia  (triangular  ligament) .  The  fibrous  layer  which  is  derived  from 
the  deep  perineal  fascia  invests  the  prostate,  forming  its  external 
fibrous  sheath  or  envelope,  and  is  continued  upward,  beyond  the  base 
of  the  prostate,  upon  the  bladder,  covering  in  the  vesicula?  seminales 
and  serves  to  retain  these  latter  organs  in  close  relationship  with  the 
bladder. 

Blood-supply. — The  prostate  is  supplied  by  branches  from  the 
internal  pudic,  vesical,  and  hemorrhoidal  arteries.  Its  veins  form 
a  plexus  around  the  base  and  sides  of  the  gland,  receiving  in  front 
the  dorsal  vein  of  the  penis  and  terminating  in  the  internal  iliac 
veins.  The  venous  plexus  is  situated  beneath  the  fibrous  sheath, 
between  this  layer  and  the  true  capsule  of  the  gland. 

OPERATIONS  UPON  THE  PROSTATE. 

Prostatectomy. — Extirpation  of  the  prostate  gland.  For  the  pur- 
pose of  relieving  the  obstruction  offered  by  the  hypertrophied  gland 
to  the  proper  evacuation  of  the  bladder. 

The  prostate  may  be  removed  either  from  within  the  bladder 
through  a  suprapubic  incision  or  else  through  an  incision  which  is 
made  in  the  perineum. 

Suprapubic  Prostatectomy. — The  operation  of  Belfield,  Mc- 
GTill,  Fuller,  and  Freyer.  Especially  adapted  for  cases  of  enormous 
hypertrophy  and  particularly  of  the  middle  portion  of  the  gland  and 
for  tumors  high  up  and  projecting  decidedly  into  the  bladder.  The 
mortality  is  greater  following  suprapubic  prostatectomy  than  perineal 
prostatectomy. 

The  bladder  is  washed  out  with  boric-acid  solution,  8  or  10  ounces 
being  permitted  to  remain  in  the  organ. 


500  URINARY  SYSTEM. 

A  suprapubic  C}Tstotomy  is  made  as  already  described,  with  the 
patient  lying  upon  the  back.  The  incision  in  the  abdomen  and  blad- 
der may  be  held  open  with  long,  broad  retractors  and  the  interior  of 
the  bladder  explored. 

The  retractors  are  then  removed  and  the  fingers  of  the  left  hand 
introduced  into  the  bladder  to  guide  the  scissors  with  which  the  wall 
of  the  bladder  is  incised.  The  enlarged,  prominent  prostate  is  readily 
recognized  by  the  fingers  in  the  bladder.  The  incision  is  made  with 
the  long  scissors  and  extends  through  the  entire  thickness  of  the 
bladder  wall  down  to  the  proper  capsule  of  the  hypertrophied  prostate ; 
it  is  placed  transversely  and  just  behind  the  urethral  orifice,  and  is 
made  sufficiently  large  to  admit  the  finger.  With  the  finger,  working 
between  the  wall  of  the  bladder  and  the  prostate,  the  entire  hyper- 
trophied gland  inclosed  in  its  proper  capsule  is  enucleated  in  one  or 
several  pieces.  Occasionally  the  two  lobes  separate  along  their  nor- 
mal line  of  cleavage  upon  the  Upper  surface  and  if  not  too  large  the 
entire  hypertrophied  gland  can  be  enucleated  in  one  single  mass. 
If  very  large  it  may  be  necessary  to  remove  the  gland  in  several  pieces, 
two  or  three.  In  performing  this  step  of  the  operation  the  finger 
should  work  close  to  the  prostatic  mass,  and  pains  should  be  taken 
not  to  injure  the  rectum.  Assistance  may  be  rendered  by  grasping 
the  mass  with  the  volsella  forceps  for  the  purpose  of  making  traction. 
The  mass  should  be  detached  from  around  the  prostatic  urethra  with- 
out injuring  the  latter.  A  catheter  may  be  introduced  into  the  urethra 
and  permitted  to  remain  during  this  part  of  the  operation.  With  two 
fingers  in  the  rectum  the  prostatic  mass  is  forced  up  against  the  fingers 
working  in  the  bladder. 

When  the  enucleation  has  been  completed  the  outside  fibrous 
sheath  of  the  prostate  and  the  prostatic  urethra  should  be  left  remain- 
ing intact.  The  cavity  that  remains  after  the  prostate  has  been  shelled 
out  is  partly  obliterated  by  collapse  of  its  walls. 

Usually  the  hemorrhage  is  not  excessive,  and  may  be  controlled  by 
irrigation  with  hot  saline. 

Two  rubber  tubes  are  introduced  into  the  bladder  through  the 
suprapubic  wound  for  drainage  and  the  incision  closed  in  part. 

Occasionally  the  hemorrhage  is  severe,  and  it  may  be  necessary 
to  tampon  the  bladder  to  control  it. 

Perineal  Prostatectomy. — Favorite  route  with  most  surgeons 
and  especially  for  lateral  lobe  hypertrophies.  It  is  followed  by  a 
smaller  mortality  than  the  suprapubic  method. 


OPERATIONS  UPON  THE  PROSTATE.  501 

With  the-  patient  lying  upon  the  back  a  metal  sound  or  guide  is 
introduced  into  the  bladder  and  the  patient  then  placed  in  the  lithot- 
omy position. 

A  curved  incision  is  made  in  front  of  the  anus  with  its  convexity 
forward  and  reaching  from  near  one  tuber  ischii  to  the  other ;  to  this 
may  be  added  a  median  incision,  which  commences  anteriorly  near  the 
base  of  the  scrotum.  The  incision  penetrates  through  the  skin,  fat, 
and  superficial  fascia,  exposing  the  sphincter  ani  and  levator  ani 
muscles;   the  prostate  gland  lies  beneath  the  levator  ani. 

The  lower  end  of  the  rectum  is  detached  and  displaced  backward 
toward  the  coccyx.  This  is  accomplished  by  cutting  the  anal  muscular 
attachments  from  the  middle  tendinous  point  of  the  perineum  (page 
488),  and  incising  the  anterior  or  inner  edges  of  the  leva  tores  ani 
muscles  (see  Pig.  215).  Working  bluntly  with  the  finger,  the  rectum 
is  still  further  detached  and  displaced  backward  so  as  to  expose  the 
posterior  surface  and  base  of  the  prostatic  mass.  The  operator  must 
be  careful  not  to  injure  the  rectum.  We  are  then  ready  for  the 
next  step  of  the  operation,  the  enucleation  of  the  prostatic  mass  from 
out  of  its  fibrous  sheath  or  envelope.  In  order  to  facilitate  this  part 
of  the  operation  the  prostate  must  be  drawn  or  pushed  down  into  the 
incision  and  steadied  there.  It  may  be  drawn  down  with  any  one  of 
the  various  tractors;  those  of  Albarran,  Young,  and  Lydston  are  of 
steel,  and  that  of  Syms  is  a  rubber  bag  which  may  be  distended  with 
water  after  it  has  been  introduced.  The  tractor  is  passed  into  the 
bladder  beyond  the  prostatic  mass  through  an  opening  which  is  made 
for  the  purpose  in  the  deep  urethra  just  in  front  of  the  prostate.  If 
the  tractor  is  used  care  must  be  exercised,  especially  after  the  prostate 
has  been  pretty  well  detached  and  while  working  around  the  upper 
part, — base,  etc.,  of  the  prostate, — that  too  much  traction  is  not  used 
because,  the  support  having  been  removed  from  the  prostate  below, 
there  is  danger  of  tearing  abruptly  through  the  mucous  membrane  of 
the  bladder.  The  prostate  may  be  forced  down  into  the  wound  with 
two  fingers  in  the  rectum  or  by  pressure  above  the  pubes,  or,  according 
to  G-uiteras,  through  a  suprapubic  incision  which  extends  down  to,  but 
not  into,  the  bladder,  into  the  space  of  Eetzius.  Probably  the  last- 
mentioned  measure  would  be  of  service  in  corpulent  subjects. 

The  fibrous  sheath  of  the  prostate  is  incised  in  the  middle  line 
from  the  apex  of  the  gland  backward  to  its  base,  and  through  this 
incision  the  sheath  is  stripped  off  the  gland  first  on  one  side  and  then 
on  the  other,  working  well  around  on  each  side  and  backward  toward 


502  URINAHY  SYSTEM. 

the  base  as  far  as  possible.  This  part  of  the  operation  may  be  'done 
with  the  finger  or  the  blunt  dissector  and  is  usually  not  difficult  nor 
accompanied  by  much  hemorrhage.  Occasionally  the  sheath  is  closely 
adherent  to  the  prostatic  mass,  and  its  detachment  under  these  cir- 
cumstances may  be  difficult  and  accompanied  with  considerable  hem- 
orrhage. 

After  the  sheath  has  been  thus  detached  the  prostate  is  split  from 
the  membranous  urethra  in  front  backward  for  about  two-thirds  of  its 
length  upon  the  metal  sound. 

The  next  step  of  the  operation  consists  in  detaching  the  prostatic 
portion  of  the  urethra  from  the  prostatic  mass.  The  edge  of  the  split 
prostatic  urethra  is  seized  with  a  toothed  forceps  and  separated  from 
the  prostatic  mass  with  the  finger  or  the  blunt  dissector  in  a  manner 
analogous  to  that  employed  in  detaching  the  fibrous  sheath,  first  on 
one  side  and  then  on  the  other.  Special  care  must  be  exercised  to 
separate  the  urethra  in  its  entire  thickness  from  the  prostatic  mass 
so  as  to  preserve  its  deeper  layer,  which  contains  the  muscular  ele- 
ments that  are  so  necessary  to  the  proper  control  of  micturition.  After 
one  lobe  has  been  thus  partially  detached  it  is  seized  with  the  forceps, 
volsella,  and  dragged  out  of  the  incision  in  the  sheath.  Any  fibrous 
strands  that  resist  this  attempt  are  cut  with  the  scissors  close  to  the 
prostate.  The  mass  is  seized  progressively  higher  and  higher  and 
drawn  further  and  further  out  of  the  incision  in  the  sheath  until  the 
upper,  back  part,  that  which  corresponds  to  the  base  of  the  bladder, 
is  drawn  into  the  field.  The  bladder  wall,  which  is  sometimes  very 
thin,  is  carefully  peeled  away  from  this  part  of  the  gland,  either 
bluntly  with  the  finger  or  blunt  dissector  or  else,  if  necessary,  with 
the  assistance  of  the  knife.  In  this  way  the  lobe  is  finally  shelled  out 
of  its  sheath.  These  procedures  are  repeated  on  the  other  side  and  the 
second  lobe  removed  in  a  similar  manner.  Occasionally,  if  the  con- 
nective-tissue interval  between  the  prostate  lobe  and  its  sheath  and  the 
urethra  is  not  well  pronounced  the  enucleation  of  the  lobe  is  difficult 
or  impossible,  and  in  order  to  remove  the  gland  it  may  be  necessary 
to  drag  it  out  through  the  incision  in  its  sheath,  piece  by  piece,  cutting 
them  away,  and  thus  remove  it  piecemeal. 

After  the  extirpation  has  been  completed  the  prostatic  urethra 
will  be  found  b^ggy,  sacculated,  and  the  finger  can  be  introduced 
through  it  into  the  bladder  without  meeting  any  obstacle.  Search  for 
stones,  which  are  frequently  present,  should  be  made.  Even  larger 
stones  can  be  removed  through  the  roomy  prostatic  urethra.     The 


Fig.  217.— Perineal  Prostatectomy.  The  sheath  of  the  prostate  has 
been  opened  and  partly  detached  from  both  lobes  and  is  drawn  aside 
with  tractors.  The  prostate  body  has  been  split  in  the  middle  line 
and  the  prostatic  urethra  opened  from  the  membranous  portion,  just 
behind  the  bulb,  backward,  upon  the  metal  sound  within  the  urethra. 
The  right  lobe  of  the  prostate,  grasped  with  a  vulsella,  has  been 
almost  completely  euucleated. 


OPERATIONS  UPON  THE  PROSTATE.  503 

redundant  edges  of  the  prostatic  urethra  are  trimmed  off  and  united 
with  catgut  sutures  over  a  rubber  catheter  introduced  through  the 
urethra  or  else  the  opening  in  the  urethra  may  be  left  partly  open  and 
a  rubber  catheter  introduced  into  the  bladder  through  the  perineum. 
The  edges  of  the  empty  prostatic  sheath  are  trimmed  away. 

Bleeding  during  the  operation  is  usually  not  excessive  unless  the 
sheath  is  firmly  adherent  to  the  prostate,  and  then  the  detachment  may 
be  accompanied  by  considerable  venous  hemorrhage.  This  may  be 
controlled  by  pressure  with  hot  pads. 

The  wound  is  packed  with  gauze  and  the  incision  in  the  peri- 
neum partly  closed  with  silk  sutures.  As  a  result  of  this  operation 
control  over  micturition  and  the  power  to  empty  the  bladder  spon- 
taneously may  frequently  be  regained  even  after  many  years  of  cathe- 
ter life. 

Method  of  Young. — Each  half  of  the  prostate  is  enucleated  from 
the  corresponding  portion  of  its  sheath  without  in  jurying  the  ejacu- 
latory  ducts. 

A  tunneled  sound  is  introduced  into  the  urethra  and  the  patient 
then  placed  in  the  lithotomy  position.  An  incision,  shaped  like  an 
inverted  V,  is  made  in  front  of  the  anus  through  the  skin,  fat,  etc., 
and  the  attachment  of  the  anal  muscles,  sphincter  ani,  etc.,  to  the 
middle  tendinous  point  of  the  perineum  is  divided  with  the  knife. 
The  lower  end  of  the  rectum  is  then  retracted  backward  toward  the 
coccyx,  and  the  prostate  exposed. 

The  membranous  portion  of  the  urethra  immediately  in  front  of 
the  apex  of  the  prostate  is  incised  upon  the  tunneled  sound,  which  is 
then  removed  and  the  tractor  introduced.  The  tractor,  closed,  is 
passed  into  the  bladder  and  up  beyond  the  prostatic  mass,  and  its 
blades  then  spread  by  turning  the  arm  at  the  handle.  With  this  in- 
strument the  prostate  is  drawn  down  into  the  incision  in  the  peri- 
neum and  its  entire  under  surface  and  base  exposed. 

Two  incisions  are  made,  one  on  either  side  of  the  middle  line, 
extending  nearly  the  entire  length  of  the  prostate  and  about  1  cm. 
deep.  The  two  incisions  approach  each  other  in  front,  being  about 
1.5  cm.  apart  anteriorly  and  1.8  cm.  posteriorly.  The  bridge  of  tissue 
between  these  two  incisions  corresponds  to  the  course  of  the  ejaculatory 
ducts,  and  its  preservation  is  necessary  if  the  ducts  are  to  be  saved  from 
injury.  The  incisions,  being  1  cm.  deep,  reach  into  the  substance  of 
the  prostate  beyond  the  level  of  the  ducts  and  close  to  the  sides  of  the 
urethral  canal. 


504 


URINARY  SYSTEM. 


The  fibrous  sheath  is  separated  from  the  prostate  with  the  blunt 
dissector.  It  is  important  to  start  in  the  correct  line  of  cleavage. 
As  this  step  of  the  operation  progresses  the  lobe  is  draAvn  more  and 
more  out  of  its  sheath.  The  urethra  is  then  detached  from  the  gland 
first  on  one  side  and  then  on  the  other,  drawing  down  with  the  tractor 
at  the  same  time.  In  detaching  the  upper  part  of  the  prostate,  that 
part  which  corresponds  to  the  bladder,  care  must  be  exercised  to  sepa- 
rate the  wall  of  the  bladder  without  injuring  it. 

If,  after  both  lobes  have  been  enucleated,  a  median  portion  still 
remains,  this  may  be  drawn  down  with  the  tractor  so  that  it  will 


Fig.  21S. — Young  s  Tractor  Closed. 


Fig.  219.— Young's  Tractor  Open. 

present  in  either  one  of  the  empty  pockets  from  which  the  lateral 
lobes  have  been  extirpated,  assisting  this  maneuver  by  pushing  with 
the  finger  in  the  other  pockets,  and  while  the  mass  is  steadied  in  this 
position  it  may  be  seized  and  enucleated. 

Two  rubber  tubes,  tied  together,  side  by  side,  are  introduced 
through  the  opening  in  the  deep  urethra  into  the  bladder  for  drainage. 
The  wound,  including  the  empty  prostatic  sheath,  is  packed  with  gauze 
and  partly  closed  with  several  silk  sutures. 

Prostatotomy  (Bottini's  Operation). — This  operation  consists  in 
cutting  through  the  prostatic  mass  with  a  heated  blade  introduced  into 
the  bladder  through  the  urethra.  The  operation  is  especially  adapted 
to  old  and  feeble  subjects  and  those  who  suffer  from  kidney  disease. 


Fig.  220. — Perineal  Prostatectomy  (Young).  Membranous  urethra  opened  just 
anterior  to  prostate  and  tractor  introduced.  Incision  through  the  sheat'i  of  prostate. 
Detaching  the  sheath  from  the  right  lobe  with  the  bluut  dissector. 


OPERATIONS  UPON  THE  PROSTATE.  505 

The  necessary  apparatus  consists  of  an  incisore  prostatico,  a 
battery,  and  a  rheostat  to  regulate  the  current  accurately. 

One  should  have  previously  made  an  examination  with  the  cys- 
toscope  for  stone,  etc.  The  patient  lies  upon  the  back  with  his  legs 
hanging  over  the  end  of  the  table  and  the  thighs  spread  apart.  The 
bladder  should  contain  about  6  ounces  of  boric-acid  solution. 

Usually  sufficient  local  anaesthesia  is  obtained  by  the  use  of  a 
solution  of  coeain  which  is  thrown  into  the  urethra  and  stripped 
backward  into  the  posterior  urethra  with  the  finger,  or  a  general 
anaesthetic  may  be  employed.  With  the  finger  in  the  rectum  the 
size  and  the  shape  of  the  prostatic  tumor  may  be  determined. 

The  incisore  is  introduced  into  the  bladder  beyond  the  enlarged 
prostate  and  its  nose  turned  downward  toward  the  base  of  the  blad- 
der, so  that,  as  it  is  slowly  withdrawn,  it  catches  or  hooks  upon  the 
prostatic  mass.  The  extremity  of  the  instrument  may  be  felt  with 
the  finger  in  the  rectum  through  the  bladder  wall  above  the  prostatic 
tumor.  The  instrument  is  now  held  firm  and  steady  in  the  whole  of 
the  left  hand  and  the  current  closed  and  regulated  by  the  rheostat 
until  sufficiently  strong  to  give  a  red  heat,  which  usually  requires 
fifteen  seconds.  T^Tow,  slowly  turning  the  screw  in  the  handle  of  the 
instrument,  the  heated  blade  is  gradually  withdrawn,  thus  burning 
a  furrow  through  the  prostatic  mass.  If  the  ear  is  held  near  the 
symphysis,  a  sizzling  sound  can  be  heard.  If,  in  withdrawing  the 
blade,  we  note  increased  resistance  in  the  mass,  the  current  is  aug- 
mented; if  too  little  resistance  to  the  blade — if  it  cuts  too  easily — 
the  current  is  correspondingly  diminished.  After  the  incision  has 
been  made  sufficiently  long  the  blade  is  shoved  back  with  a  little 
increase  of  the  current. 

Several  such  incisions  or  channels  should  be  made  in  the  prostatic 
mass,  usually  three :  one  in  the  middle  line,  toward  the  rectum  with 
the  beak  of  the  instrument  directed  downward,  and  two  lateral,  one  on 
each  side  of  the  middle  line.  The  incision  through  the  upper  part 
of  the  prostate  with  the  beak  of  the  instrument  directed  upward  toward 
the  symph}Tsis  may  well  be  omitted,  because,  in  the  first  place,  it  is 
unnecessary  and,  in  the  second,  it  is  dangerous  on  account  of  the  ease 
with  which  the  blade  may  cut  through  the  neck  of  the  bladder  into 
the  space  of  Eetzius.  Before  commencing  the  incisions  the  beak  of 
the  instrument  within  the  bladder  should  be  felt  for  above  the  pro- 
static mass  with  the  finger  in  the  rectum  in  order  to  make  certain 
that  it  has  not  slipped  forward,  over  the  prostatic  mass,  into  the  deep 
urethra. 


506  URINARY  SYSTEM. 

The  entire  operation  should  occupy  from  five  to  ten  minutes. 

The  permanent  benefit  that  is  derived  from  this  operation  depends 
upon  the  contraction  which  accompanies  the  cicatrization  of  the  fur- 
rows that  are  burned  in  the  prostatic  mass. 

The  incisore  resembles  a  lithotrite,  having  a  male  and  a  female 
blade,  the  male  blade  fitting  into  the  female  and  consisting  of  plati- 
num iridium,  which  may  be  heated  to  any  degree  by  the  electric  cur- 
rent, whose  strength  is  regulated  by  the  rheostat. 

By  turning  the  screw  at  the  handle  the  male  blade  is  withdrawn 
from  the  groove  in  the  female  blade,  and  is  thus  made  to  cut  or  burn 
its  way  through  the  hypertrophied  prostatic  mass. 

The  shaft  of  the  instrument  is  hollow,  so  that  it  may  be  supplied 
with  a  current  of  cold  water,  which  flows  in  through  one  tube  and  out 
through  another;  these  tubes  are  both  placed  near  the  handle.  The 
cold  water  current  is  for  the  purpose  of  keeping  that  part  of  the 
instrument  cool  which  rests  in  the  anterior  part  of  the  urethra. 

The  incisore  as  improved  by  Young  has  many  advantages.  The 
beak  of  Young's  instrument  is  more  sharply  curved  and  therefore  is 
less  liable  to  slip  forward  over  the  prostatic  mass  into  the  deep  urethra 
and  it  is  provided  with  four  interchangeable  blades  of  different  sizes 
and  different  degrees  of  curvature  so  that  an  appropriate  blade  for 
each  case  can  be  selected. 

Immediately  before  using  the  instrument  it  should  be  tested  with 
the  current,  and  an  observation  made  upon  the  rheostat  to  determine 
just  what  degree  of  current  is  necessary  to  bring  the  blade  to  the 
proper  heat;  usually  about  45  amperes  are  required.  The  screw  in 
the  handle  permits  of  an  incision  up  to  4  cm.  in  length  being  made. 


PART  IX. 

THE  UPPER  EXTREMITY. 


THE  AXILLA. 

The  Axilla  is  a  four-sided  pyramidal  space.  Its  apex  is  above, 
and  corresponds  to  the  depression  upon  the  upper  surface  of  the  first 
rib,  external  to  the  attachment  of  the  tendon  of  the  scalenus  anticus 
muscle,  where  the  subclavian  artery  enters  the  axillary  space  to  be- 
come the  axillary.  The  base  of  the  axilla  corresponds  to  the  fold  of 
skin  and  fascia  which  is  stretched  between  the  edge  of  the  pectoralis 
major  in  front  and  that  of  the  latissimus  dorsi  behind. 

The  anterior  wall  of  the  axilla  is  made  up  of  the  pectoralis  major 
and  pectoralis  minor;  the  posterior  wall  is  formed  by  the  subscapularis 
and  the  tendon  of  the  latissimus  dorsi  and  the  teres  major.  The  inner 
wall  corresponds  to  the  side  of  the  chest,  and  is  made  up  of  the  first, 
second,  third,  and  fourth  ribs  and  corresponding  intercostal  muscles 
and  the  upper  serrations  of  the  serratus  magnus.  The  outer  wall  of 
the  axilla  is  a  narrow  space,  which  is  included  between  the  anterior 
and  posterior  walls  and  corresponds  to  the  floor  of  the  bicipital  groove. 
In  the  bicipital  groove  is  lodged  the  long  tendon  of  the  biceps.  The 
coraeo-brachialis  muscle,  which  arises  from  the  coracoid  process,  de- 
scends in  the  outer  part  of  the  axillary  space,  lying  close  to  the 
humerus. 

To  the  anterior  lip  of  the  bicipital  groove  is  attached  the  tendon 
of  the  pectoralis  major,  and  to  its  posterior  lip  are  attached  the  ten- 
dons of  the  latissimus  dorsi  and  teres  major. 

The  contents  of  the  axilla  consist  of  the  axillary  artery  and  vein, 

'the  large  nerve-trunks  which  are  derived  from  the  brachial  plexus, 

lymphatic  vessels  and  nodes,  and  a  mass  of  loose  connective  tissue  and 

fat  which  is  continuous  with  the  connective  tissue  and  fat  of  the  root 

of  the  neck  and  the  mediastinum. 

The  Axillaey  Artery. — The  axillary  artery  is  the  continuation 
of  the  subclavian,  and  passes  through  the  axillary  space  from  its  apex 
to  its  base,  where  it  is  prolonged  downward  into  the  arm  as  the  brach- 
ial. The  vessel  passes  through  the  upper  part  of  the  axillary  space, 
(507; 


508 


UPPER  EXTREMITY. 


lying  close  to  its  anterior  wall.  The  lower,  or  outer,  portion  of  the 
artery  lies  close  to  the  humerus,  beneath  the  edge  of  the  coraco-brachi- 
alis,  resting  upon  the  tendon  of  the  latissimus  dorsi,  and  covered  by 
the  pectoralis  major.  The  axillary  vein,  which  is  sometimes  double, 
accompanies  the  artery,  lying  below  it,  and  both  artery  and  vein  are 
in  close  relation  with  the  nerve-trunks  which  traverse  the  axillary 
space.  With  the  arm  extended  to  a  right  angle,  the  course  of  the 
artery  is  nearly  straight,  and  corresponds  to  an  imaginary  line  which 
is  drawn  from  the  junction  of  the  inner  and  middle  thirds  of  the  clav- 


Fig.  221.— Axillary  Region.  Costo-coracoid  membrane  has  been  cleared 
away  to  show  upper  part  of  the  axillary  vessels,  etc.  C.Y.,  cephalic  vein; 
EX. O.N. ,  external  cutaneous  nerve;  IN. C.N. ,  internal  cutaneous  nerve; 
M.N.,  median  nerve;  S.V.,  subscapular  vein;  V.N.,  ulnar  nerve. 

icle  to  a  point  upon  the  front  of  the  elbow  midway  between  the  two 
condyles;  with  the  arm  hanging  by  the  side,  the  artery  describes  a 
curve  which  is  convex  upward  and  outward. 

After  the  pectoralis  major  has  been  separated  from  its  attach- 
ment to  the  clavicle  and  reflected  downward,  the  pectoralis  minor, 
together  with  the  costo-coracoid  membrane,  will  be  exposed.  The 
costo-coracoid  membrane  is  a  rather  thickened  sheath  of  fascia  which 
reaches  from  the  inner  border  of  the  pectoralis  minor  upward,  to  be 
attached  to  the  under  surface  of  the  clavicle  and  to  the  first  rib;  it 
is  simply  a  reflection  of  the  deep  fascia  which  invests  the  pectoralis 


AXILLA.  509 

minor,  and  serves  to  cover  in  the  upper,  or  first,  part  of  the  axillary 
vessels  and  adjoining  structures. 

The  axillary  artery  is  crossed  about  its  middle  by  the  pectoralis 
minor  muscle,  and  may  be  conveniently  considered  in  three  parts. 
The  upper,  or  first,  part  of  the  artery  reaches  from  its  commencement 
at  the  first  rib  to  the  inner  border  of  the  pectoralis  minor,  and  is  not 
exposed  until  after  the  costo-coracoid  membrane  has  been  cleared 
away;  the  second  part  of  the  artery  is  that  portion  which  lies  behind 
the  pectoralis  minor  muscle,  and  the  third  is  that  part  which  reaches 
from  the  outer  border  of  pectoralis  minor  to  the  point  below  where  it 
becomes  the  brachial. 

In  the  first  part  of  its  course  the  three  trunks  of  the  brachial 
plexus  lie  above  the  axillary  artery.  In  the  second  part  of"  its  course 
one  trunk  lies  above,  one  behind,  and  one  below  it.  In  the  third  part 
the  cords  of  the  brachial  plexus  communicate  with  each  other,  sur- 
rounding the  axillary  artery,  and  divide  into  a  number  of  branches  to 
supply  the  upper  extremity.  The  median  nerve  lies  external  to  the 
artery,  taking  one  root  from  the  external  cord  of  the  plexus  and  a 
second  root  from  the  internal  cord,  the  latter  root  passing  across  the 
front  of  the  artery.  The  external  cutaneous  nerve  also  lies  to  the 
outer  side  of  the  vessel,  being  derived  from  the  outer  cord  of  the 
plexus.  To  the  inner  side  of  the  artery,  and  derived  from  the  inner 
cord,  are  the  ulnar,  internal  cutaneous,  and  lesser  internal  cutaneous 
nerves.  Derived  from  the  posterior  cord  of  the  brachial  plexus  and 
situated  behind  the  artery  are  the  posterior  circumflex  and  the  mus- 
culo-spiral  nerves.  Immediately  after  its  origin  the  circumflex  passes 
directly  backward  between  the  subscapularis  and  latissimus  dorsi  (and 
teres  major)  muscles,  and  is  distributed  to  the  deep  surface  of  the 
deltoid. 

The  cephalic  vein  pierces  the  costo-coracoid  membrane  and  passes 
across  the  first  part  of  the  axillary  artery  to  empty  into  the  axillary 
vein. 

The  lymphatic  vessels  and  nodes  are  intimately  related  to  the 
axillary  vessels  along  their  whole  course  within  the  axilla. 

From  the  upper,  or  first,  part  of  artery  are  given  off  the  superior 
thoracic  and  acromial  thoracic  branches,  which  are  distributed  to  the 
anterior  wall  of  the  axilla  and  to  the  axillary  contents.  A  branch  from 
the  acromial  thoracic  is  found  in  company  with  the  cephalic  vein  in 
the  groove  between  the  deltoid  and  pectoralis  major  muscles  (Mohren- 
heim's  fossa). 


510  UPPEK  EXTREMITY. 

At  the  lower  border  of  the  pectoralis  minor  the  long  thoracic  is 
given  off;  this  branch  passes  downward  close  to  the  lower  border  of 
this  muscle,  lying  beneath  the  edge  of  the  pectoralis  major,  and  ram- 
ifies upon  the  side  of  the  chest. 

Still  lower,  and  close  to  the  posterior  wall  of  the  axilla,  the  artery 
gives  off  the  subscapular,  a  large  branch  which  descends  upon  the 
posterior  wall  of  the  axilla,  along  the  outer  border  of  the  subscapularis 
muscle;  it  is  accompanied  by  the  large  subscapular  nerve,  and  enters 
and  supplies  the  latissimus  dorsi.  External  to  this  branch  is  given 
off  the  posterior  circumflex,  which  passes  backward  between  the  latissi- 
mus dorsi  and  subscapularis  muscles  together  with  the  circumflex 
nerve;  they  wind  around  the  surgical  neck  of  the  humerus  beneath 
the  deltoid,  which  they  supply.  The  axillary  vessels  and  adjoining 
nerves,  etc.,  in  the  upper,  or  inner,  part  of  the  axillary  space,  are 
located  close  to  the  anterior  wall,  and  in  the  lower,  or  outer,  part  of 
the  axilla  they  are  found  close  to  the  humerus,  resting  upon  the 
tendon  of  the  latissimus  dorsi  and  beneath  the  edge  of  the  coraco- 
brachialis.  Branches  of  the  axillary  artery  ramify  upon  the  anterior 
and  posterior  walls  of  the  axillary  space,  and,  descending  upon  the 
inner  wall,  side  of  the  chest,  posteriorly,  is  the  long  thoracic  nerve, 
which  supplies  the  serratus  magnus;  the  middle  of  the  axilla  is, 
therefore,  free  for  incisions  for  abscess,  etc.;  if  it  is  desired  to  ex- 
tirpate completely  the  axillary  contents,  it  is  well  to  commence  by 
making  a  clean  dissection  of  the  main  vessels  and  nerves. 

THE  ARM. 

Upon  the  front  of  the  arm  there  is  seen  a  prominent  spindle- 
shaped  mass,  which  consists  of  the  belly  of  the  biceps  and,  joined  to 
its  inner  side,  the  coraco-brachialis  muscle.  Occupying  the  inner  side 
and  back  of  the  arm  is  a  thick  mass  of  muscle,  the  triceps.  Upon  the 
outer  side,  above,  covering  over  the  shoulder-joint,  is  a  large  mass  of 
muscle,  the  deltoid.  Beneath  the  deltoid,  between  it  and  the  surgical 
neck  of  the  humerus,  the  circumflex  nerve  and  the  circumflex  arteries 
are  found.  The  circumflex  nerve,  although  well  protected  by  the  mass 
of  deltoid  muscle,  on  account  of  its  relation  with  the  neck  of  the 
humerus  is  often  injured  by  blows  and  falls  upon  the  shoulder,  with 
a  resulting  disability  of  the  deltoid. 

Vessels  of  Arm.  The  Brachial  Artery. — In  the  depression 
corresponding  to  the  inner  margin  of  the  biceps  and  coraco-brachialis, 


Fig.  222.— Section  through  Middle  of  Eight  Arm.  B.A.,  brachial  artery  ; 
C,  T~,  cephalic  vein;  M.N.,  median  nerve;  M.S.N.,  musculo-spiral  nerve; 
U.N.,  ulnar  nerve. 


ARM.  511 

beneath  the  deep  fascia,  lies  the  brachial  artery.  The  brachial  artery 
is  the  continuation  of  the  axillary ;  it  passes  down  along  the  inner  side 
of  the  arm  in  the  space  between  the  anterior  muscular  mass,  biceps,  etc., 
and  the  inner  muscular  mass,  triceps;  externally  and  behind,  the 
artery  rests  against  the  humerus,  and  below  the  bend  of  the  elbow  it 
divides  into  the  radial  and  ulnar. 

The  linear  guide  to  the  artery  with  the  arm  abducted  is  a  line 
drawn  from  the  coracoid  process  to  a  point  upon  the  front  of  the 
elbow,  midway  between  the  condyles ;  the  muscular  guide  is  the  inner 
edge  of  the  biceps  and  the  coraco-brachialis  muscles. 

The  brachial  artery  is  covered  by  the  integument  and  deep  fascia, 
and  is  accompanied  by  two  veins,  venae  comites,  which  lie  directly 
upon  the  vessel  and  anastomose  with  each  other  by  numerous  trans- 
verse branches.  Above  the  median  nerve  lies  to  the  outer  side  of  the 
brachial  artery,  crosses  the  artery  about  its  middle,  and  below  lies  to 
its  inner  side;  the  ulnar  and  internal  cutaneous  nerves  are  situated 
upon  the  inner  side  of  the  artery,  the  ulnar  resting  upon  the  inner 
head  of  the  triceps  and  gradually  getting  farther  away  from  the  ar- 
tery as  it  descends  to  reach  the  back  of  the  internal  condyle.  Behind 
the  artery,  in  the  upper  part  of  the  arm,  the  musculo-spiral  nerve  is 
located. 

The  basilic  vein  runs  parallel  with  the  brachial  artery,  lying 
superficial  to  it  and  rather  to  its  inner  side.  One  may  meet  this  vein 
in  making  the  incision  to  expose  the  brachial  artery.  In  the  lower 
half  of  the  arm  this  vein  is  separated  from  the  artery  by  the  deep 
fascia,  but  about  the  middle  of  the  arm  it  pierces  the  deep  fascia,  and 
thus  gets  into  closer  relation  with  the  artery.  In  the  upper  part  of 
the  arm  the  basilic  vein  joins  the  venge  comites  to  form  the  axillary 
vein.  Along  the  outer  side  of  the  arm,  superficial  to  the  deep  fascia, 
runs  the  cephalic  vein ;  above  this  vein  is  found  in  the  groove  between 
the  pectoralis  major  and  the  deltoid,  and,  after  piercing  the  costo- 
coracoid  membrane,  passes  across  the  first  part  of  the  axillary  artery 
to  empty  into  the  axillary  vein. 

At  the  Elbow,  upon  the  front  aspect  of  the  arm,  there  is  a  tri- 
angular space  with  its  apex  directed  downward;  the  inner  border  of 
the  space  is  formed  by  the  pronator  radii  teres,  passing  obliquely 
downward  and  outward  from  the  internal  condyle;  the  outer  border 
is  formed  by  the  spinator  longus,  and  its  floor  by  the  brachialis  anti- 
cus  and  supinator  brevis.  In  this  spaces  are  found  the  tendon  of  the 
biceps,  the  brachial  artery,  and  its  accompanying  veins,  the  median 


512  UPPER  EXTREMITY. 

and  the  musculo-spiral  nerves,  and  the  bifurcation  of  the  brachial 
artery  into  the  radial  and  ulnar,  which  occurs  about  one  inch  below 
the  bend  of  the  elbow.  In  this  space  the  median  nerve  is  about  half 
an  inch  to  the  inner  side  of  the  brachial  artery,  owing  to  the  latter's 
verging  outward,  away  from  the  nerve,  toward  the  middle  line. 

The  musculo-spiral  nerve  lies  in  the  outer  part  of  the  space  upon 
the  supinator  brevis,  and  is  covered  by  the  overlapping  edge  of  the 
supinator  longus.  This  region  is  covered  by  the  skin,  superficial  and 
deep  fascia.  The  skin  of  this  region  has  a  marked  tendency  to  retract 
when  cut,  and  this  should  be  remembered  in  marking  out  the  flaps  for 
exarticulation  at  the  elbow-joint.  Lying  just  beneath  the  skin  upon 
the  deep  fascia  is  the  median  cephalic  vein  externally,  and  the  median 
basilic  internally.  The  latter,  the  median  basilic,  is  separated  from 
the  brachial  artery,  not  only  by  deep  fascia,  but  also  by  a  fibrous 
expansion  which  is  given  off  from  the  biceps  tendon  to  the  deep  fascia 
of  the  forearm.  The  median  cephalic  is  the  vein  selected  by  preference 
for  intravenous  infusion. 

The  Eadial  Artery. — From  its  origin  below  the  bend  of  the 
elbow  the  radial  passes  somewhat  outward  and  then  downward  upon 
the  outer  side  of  the  anterior  aspect  of  the  forearm ;  it  lies  superficial, 
though  partly  covered  by  the  overlapping  edge  of  the  supinator  longus. 
In  its  course  it  rests  upon  the  tendon  of  the  biceps,  the  supinator 
brevis,  the  radial  origin  of  the  flexor  sublimis  digitorum,  the  pronator 
radii  teres,  the  flexor  longus  pollicis,  and  the  pronator  quadratus.  In 
the  lower  part  of  the  forearm,  just  above  the  wrist,  the  artery  lies 
beneath  the  integument  and  the  deep  fascia,  to  the  outer  side  of  the 
tendon  of  the  flexor  carpi  radialis,  between  it  and  the  tendon  of  the 
supinator  longus. 

In  the  upper  part  of  the  forearm  the  artery  is  accompanied  by 
the  radial  branch  of  the  musculo-spiral  nerve,  which  lies  to  its  outer 
side.    Usually  two  venas  comites  accompany  the  artery. 

At  the  wrist  the  radial  artery  curves  around  the  outer  side  of 
the  joint,  beneath  the  extensor  tendons  of  the  thumb  and  resting  upon 
the  external  lateral  ligament ;  it  then  passes  across  the  posterior  surface 
of  the  scaphoid  and  trapezium,  and  then  forward,  through  the  opening 
in  the  first  dorsal  interosseous  muscle,  into  the  palm  of  the  hand. 

In  the  hand  the  radial  artery  is  situated  deep  and  passes  from 
without  inward,  resting  upon  the  bases  of  the  metacarpal  bones  and 
the  anterior  interosseous  muscles,  covered  by  all  the  structures  of  the 
hand :  tendons,  nerves,  superficial  arch,  etc.    Upon  reaching  the  inner 


Fig.  223.— Section  through  Middle  of  Bight  Forearm.  E.D., 
extensor  digit,  com.;  E.I.,  extensor  indicis  ;  E.M.,  extensor  min. 
digit  ;  E.G.,  extensor  os.  metaearpi  poh;  E.R.B.,  extensor  carp, 
rad.  brev.;  E.JR.L.,  extensor  carp.  rad.  long.;  E.S.,  extensor 
secundi  ;  El'.,  extensor  carp,  ulnar  ;  F.F.,  flexor  profund.  dig.; 
F.L.,  flexor  long.  pol.  ;  F.B.,  flexor  carp,  rad.;  F.S.,  flexor  digit 
sublim.;  F.  U.,  flexor  carp,  ulnar.;  T.A.K,  anterior  interos.  art. 
and  nerve;  M.JST.,  medifn  nerve;  P.L.,  palmaris  longus  ;  P.R., 
pronator  radii;  R.A.,  radial  art.  ;  S.L.,  supinat.  long.;  U.A.N., 
ulnar  art.   and  nerve. 


ARM.  513 

side  of  the  hand  it  anastomoses  with  the  communicating  branch  from 
the  ulnar,  and  in  this  way  completes  the  deep  palmar  arch.  The  deep 
palmar  arch  is  located  one  finger's  breadth  nearer  the  wrist- joint  than 
the  superficial  palmar  arch.  The  deep  arch  is  accompanied  by  the 
deep  branch  of  the  ulnar  nerve.  From  the  deep  arch  are  given  off 
the  palmar  interosseous  branches ;  these  descend  upon  the  interosseous 
muscles  between  the  metacarpal  bones,  and  at  the  clefts  of  the  fingers 
anastomose  with  the  branches  from  the  superficial  arch. 

The  Ulnar  Artery. — Immediately  after  its  origin  the  ulnar 
artery  approaches  the  inner  side  of  the  forearm,  passing  deep  beneath 
the  superficial  flexors,  and  lying  upon  the  flexor  profundus  digitorum ; 
the  upper  half  of  the  artery  is  thus  covered  by  the  superficial  flexors 
(pronator  radii  teres,  flexor  carpi  radialis,  palmaris  longus,  and  flexor 
sublimis  digitorum)  ;  in  the  lower  half  of  its  course  the  ulnar  artery 
is  still  found  resting  upon  the  flexor  profundus  digitorum,  but  it  is 
rather  more  superficial  and  lies  between  the  tendon  of  the  flexor 
carpi  ulnaris  internally  and  the  tendons  of  the  flexor  sublimis  digi- 
torum externally.  The  artery  is  accompanied  by  the  ulnar  nerve, 
which  lies  to  its  inner  side ;  in  the  upper  part  of  the  forearm  the 
median  nerve  lies  to  the  inner  side  of  the  artery,  but  a  short  distance 
below  it  crosses  to  its  outer  side.  The  artery  is  accompanied  by  vense 
comites.  Just  below  its  origin  the  ulnar  gives  off  the  interosseous, 
which  divides  into  an  anterior  and  a  posterior  interosseous  branch. 
The  anterior  passes  down  the  front  of  the  forearm,  resting  upon  the 
interosseous  membrane;  the  posterior  passes  through  an  opening  in 
the  upper  part  of  the  interosseous  membrane,  and  runs  down  the 
back  of  the  forearm  between  the  superficial  and  deep  layers  of  muscles. 

At  the  wrist  the  ulnar  artery  lies  superficial,  passing  across  the 
anterior  annular  ligament,  on  the  ulnar  side  of  the  hand,  just  to  the 
radial  side  of  the  pisiform  bone,  with  the  ulnar  nerve  lying  to  its 
inner  side;  here  it  turns  outward  toward  the  radial  side  of  the  hand 
and  anastomoses  with  a  branch  (superficial)  from  the  radial,  thus 
forming  the  superficial  palmar  arch. 

In  the  hand  the  superficial  palmar  arch  is  about  on  a  level  with 
the  palmar  surface  of  the  thumb  when  it  is  abducted  and  is  covered 
by  the  skin  and  palmar  fascia,  resting  upon  the  flexor  tendons,  etc.; 
it  gives  off  digital  branches,  four  in  number,  which  pass  downward 
and  after  anastomosing  with  the  palmar  interosseous  branches,  from 
the  deep  palmar  arch,  at  the  clefts  of  the  fingers,  divide  into  two 
branches  to  supply  the  contiguous  sides  of  the  fingers. 

33 


514  UPPER  EXTREMITY. 

The  Musculo-spiral  Nerve. — The  musculo-spiral  nerve  passes 
down  the  back  of  the  arm.  It  is  lodged  in  the  musculo-spiral  groove 
upon  the  posterior  surface  of  the  humerus  between  the  inner  and 
outer  heads  of  the  triceps  muscle  and  covered  by  the  long  head  of 
this  muscle.  In  its  course  it  crosses  the  posterior  surface  of  the 
humerus  obliquely  from  above  downward,  and  from  within  outward, 
and  at  the  elbow- joint  is  found  in  front  of  the  external  condyle  be- 
neath the  supinator  longus.  The  nerve  is  accompanied  by  the  supe- 
rior profunda  branch  of  the  brachial  artery. 

The  Median  Nerve. — In  the  upper  arm  the  median  nerve  is 
closely  related  with  the  brachial  artery.  In  the  forearm  it  lies  be- 
neath the  flexor  sublimis  muscle,  resting  upon  the  flexor  profundus 
digitorum.  Just  above  the  annular  ligament  this  nerve  becomes  more 
superficial,  lying  to  the  inner  side  of  the  tendon  of  the  flexor  carpi 
radialis. 

The  Ulnar  Nerve. — In  the  upper  arm  the  ulnar  nerve  lies  some 
little  distance  to  the  inner  side  of  the  brachial  artery,  resting  upon 
the  inner  head  of  the  triceps,  beneath  the  deep  fascia.  At  the  elbow 
the  ulnar  nerve  lies  behind  the  joint  in  the  groove  between  the  in- 
ternal condyle  and  the  olecranon  process;  it  then  swings  forward, 
and  is  continued  down  the  anterior  aspect  of  the  forearm,  resting 
upon  the  flexor  profundus  digitorum  beneath  the  flexor  carpi  ulnaris 
and  lying  close  to  the  inner  side  of  the  ulnar  artery. 

THE  HAND. 

Beneath  the  integument  in  the  palm  of  the  hand  is  the  palmar 
fascia.  This  is  a  dense,  aponeurotic  layer  intimately  joined  to  the 
integument. 

Beneath  the  palmar  fascia  are  the  flexor  tendons,  superficial  and 
deep  palmar  arches,  nerves,  etc.  As  the  flexor  tendons  pass  across 
the  wrist-joint  into  the  palm  of  the  hand  they  are  bound  down  by 
the  anterior  annular  ligament.  The  extensor  tendons,  as  they  pass 
over  the  back  of  the  wrist-joint  into  the  hand,  are  bound  down  by 
the  posterior  annular  ligament. 

Beneath  the  anterior  annular  ligament  the  flexor  tendons  are 
inclosed  within  a  synovial  sheath,  which  extends  for  a  short  distance 
upward  into  the  forearm  and  downward  into  the  palm  of  the  hand. 
Prom  this  common  sheath  there  are  given  off  two  processes,  one  of 
which  accompanies  and  envelops  the  tendon  of  the  flexor  longus 


HAND.  515 

pollicis  into  the  thumb;  the  other  accompanies  the  flexor  tendons 
of  the  little  finger  to  their  destination. 

The  sheaths  which  surround  the  tendons  of  the  other  fingers — 
i.e.,  the  index,  middle,  and  ring — do  not,  as  a  rule,  reach  beyond  the 
metacarpo-phalangeal  articulation,  and  do  not  communicate  with 
this  common  flexor  sheath.  This  fact  is  important  in  determining 
the  extension  of  inflammatory  processes  which  involve  the  tendon 
sheaths  of  the  fingers  up  into  the  hand  and  forearm.  Inflammatory 
processes  which  involve  the  thumb  and  little  finger  are  found  more 
apt  to  extend  into  the  hand  and  forearm  than  those  of  the  other 
fingers. 

The  hand  gets  its  arterial  supply  from  the  radial  and  ulnar  ar- 
teries (see  description  of  these  vessels). 

The  Nerve-supply  of  the  Hand. — The  nerve-supply  of  the  hand 
is  derived  from  the  median  and  ulnar  and  musculo-spiral  nerves. 
The  median  nerve  passes  into  the  palm  of  the  hand  beneath  the 
annular  ligament;  the  ulnar  nerve  passes  into  the  palm  of  the  hand 
across  the  annular  ligament:  i.e.,  in  company  with  the  ulnar  artery. 
In  the  hand,  in  close  relation  to  the  superficial  arch,  the  median  and 
ulnar  nerves  give  off  their  digital  branches,  which  supply  the  in- 
tegument of  the  palmar  aspect  of  the  fingers  with  sensation,  the 
ulnar  supplying  the  little  finger  and  half  the  ring  finger,  the  median 
supplying  the  other  fingers. 

The  dorsal  aspect  of  the  hand  and  the  fifth,  fourth,  and  part 
of  the  third  fingers  are  supplied  by  the  ulnar  nerve;  the  thumb  and 
the  second  and  part  of  the  third  fingers  are  supplied  by  the  radial 
nerve,  which  is  a  branch  of  the  musculo-spiral. 

All  the  interossei,  both  anterior  and  posterior,  and  the  two  inner 
lumbricales  are  supplied  by  the  deep  branch  of  the  ulnar  nerve  which 
accompanies  the  deep  palmar  arch;  the  two  outer  lumbricales  are 
supplied  by  the  median. 

A  collection  of  pus  in  the  palm  of  the  hand  may  be  situated 
superficially  beneath  the  skin,  between  it  and  the  palmar  fascia,  or 
deep,  beneath  the  palmar  fascia  or  within  the  proper  synovial  sheaths 
of  the  flexor  tendons'. 

Incisions  into  the  palm  of  the  hand  may  be  freely  made  without 
troublesome  hemorrhage,  if  placed  over  the  metacarpal  bones  and 
below  the  line  of  the  superficial  palmar  arch. 

Ligations.  The  Axillaey  Artery. — The  axillary  artery  is  not 
often  exposed  for  the  purpose  of  ligation,  but  frequently  the  artery  and 


516  UPPER  EXTREMITY. 

vein  and  adjoining  structures  are  laid  bare  during  the  course  of  op- 
erations which  require  a  thorough  cleaning  out  of  the  axilla. 

A  ligature  may  be  applied  to  the  third  part  of  the  axillary  artery 
as  it  lies  upon  the  tendon  of  the  latissimus  dorsi  close  to  the  hu- 
merus. The  arm  should  be  abducted  from  the  side  of  the  chest  to  a 
right  angle  and  slightly  flexed  at  the  elbow-joint,  in  order  that  the 
structures  may  not  be  placed  too  much  upon  the  stretch;  with  the 
arm  in  this  position  the  course  of  the  artery  corresponds  to  a  line 
drawn  from  the  junction  of  the  middle  and  inner  thirds  of  the 
clavicle  to  the  middle  of  the  elbow.  An  incision  two  and  one-half 
inches  long  is  made  through  the  integument  down  to  the  deep  fascia; 
this  incision  is  placed  midway  between  the  anterior  and  posterior 
borders  of  the  axilla,  along  the  edge  of  the  coraco-brachialis  muscle. 
This  incision  penetrates  through  the  skin  and  fat.  With  a  second 
stroke  of  the  knife  the  deep  fascia  is  incised,  and  one  may  then,  with 
the  handle  of  the  knife,  seek  the  white,  shiny  tendon  of  the  latis- 
simus dorsi,  which  is  the  guide  to  the  axillary  vessels  in  this  part 
of  their  course.  When  this  tendon  is  recognized,  it  is  followed  up 
toward  its  attachment  to  the  humerus,  diminishing  the  tension  of 
the  parts  by  flexing  the  arm  somewhat  at  the  elbow,  and  then  the 
vessels  and  nerves  are  readily  located,  the  vein,  which  lies  below  and 
internal  to  the  artery,  being  the  first  structure  encountered. 

The  artery  is  carefully  isolated  for  a  short  distance,  using  blunt 
hooks  to  retract  the  adjacent  structures,  and  the  loose  connective 
tissue  which  immediately  surrounds  the  vessel  is  picked  up  with  a 
toothed  forceps  and  nicked  with  the  point  of  a  knife;  through  the 
small  opening  which  is  thus  made  in  the  connective  tissue  sheath  a 
director  may  be  introduced  between  the  vein  and  the  artery  and 
gradually  worked  around  the  artery,  taking  care  to  keep  close  to  the 
wall  of  the  vessel,  so  as  not  to  include  any  of  the  adjoining  structures 
— one  should  avoid,  especially,  the  musculo-spiral  nerve,  which  is 
located  behind  the  artery,  upon  the  tendon  of  the  latissimus  dorsi. 
A  small  aneurism  needle  is  then  carried  around  the  artery,  a  ligature 
passed  through  its  eye,  and  the  needle  withdrawn,  thus  leaving  the 
vessel  surrounded  by  the  ligature,  which  is  tied  with  a  single  square 
knot. 

The  Brachial  Artery. — The  linear  guide  to  the  brachial  artery 
is  a  line  drawn  from  the  coracoid  process  to  a  point  upon  the  front 
of  the  elbow,  midway  between  the  condyles,  the  arm  being  abducted 
to  a  right  angle  with  the  trunk.    The  muscular  guide  to  the  artery  is 


LIGATIONS. 


517 


the  inner  edge  of  the  mass  of  muscle,  composed  of  the  biceps  and 
c  orae  o-bra  chialis . 

The  incision,  two  inches  in  length,  is  made  along  the  inner  bor- 
der of  the  coraco-brachialis,  penetrating  through  the  skin  and  sub- 
cutaneous fat  and  exposing  the  deep  fascia.  At  this  stage,  below 
the  middle  of  the  arm,  the  basilic  vein,  lying  superficial  to  the  deep 
fascia  and  to  the  inner  side  of  the  brachial  artery,  is  met.  In  the 
upper  part  of  the  arm  we  would  not  encounter  the  basilic  vein  until 
after  we  had  cut  through  the  deep  fascia. 

The  deep  fascia  is  now  incised  in  a  direction  corresponding  to 
the  skin  incision,  and  the  bundle  of  structures — which  consists  of 


\     '  vw 


Fig.  224.— Right  Arm.    A,  incision  for  ligation  of  axillary  artery; 
B,  incision  for  ligation  of  brachial  artery. 


the  artery,  venae  comites,  and  adjoining  nerves  and  which  is  readily 
felt  beneath  the  deep  fascia — is  exposed. 

In  the  middle  of  the  arm  we  find  the  median  nerve  lying  upon 
and  crossing  the  artery  from  without  inward;  above  the  middle  of 
the  arm  the  median  nerve  lies  close  to  the  outer  side  of  the  artery; 
below  the  middle  it  lies  along  its  inner  side.  The  ulnar  nerve  is  situ- 
ated upon  the  inner  side  of  the  artery,  getting  farther  away  from  it 
as  it  descends  toward  the  elbow-joint.  The  loose  connective  tissue 
that  surrounds  the  brachial  artery  may  be  now  picked  up  with  a 
mouse-toothed  forceps  and  nicked  with  the  point  of  the  knife; 
through  the  small  opening  thus  made  a  director  is  introduced  and 


518  UPPER  EXTREMITY. 

gradually  worked  around  the  artery,  which  is  thus  isolated  from  the 
adjoining  structures,  avoiding  the  venae  comites,  which  lie  directly 
upon  it.  A  small  aneurism  needle  is  then  passed  around  the  artery 
through  the  path  made  by  the  director,  and  after  a  ligature  is  car- 
ried through  its  eye  the  needle  is  withdrawn,  leaving  the  artery  sur- 
rounded by  the  ligature,  which  is  tied. 

The  Badial  Artery.  In  the  Middle  of  the  Forearm.  —  An  in- 
cision one  and  one-half  inches  long  is  made  between  the  middle  and 
inner  thirds  of  the  forearm,  reaching  through  the  skin  and  fat  down 
to  the  deep  fascia;  the  deep  fascia  is  then  incised  and  the  artery  found 
lying  partly  concealed  by  the  overlapping  edge  of  the  supinator  longus, 
which  is  drawn  aside  with  a  retractor.  The  artery  is  accompanied  by 
venae  comites,  which  lie  close  upon  it,  and  also  to  its  outer  side  by  the 
radial  nerve,  which  is  a  branch  of  the  musculo-spiral. 

Just  Above  the  Wrist. — Here  the  artery  is  found  beneath  the  deep 
fascia,  lying  between  the  tendons  of  the  supinator  longus  externally 
and  the  flexor  carpi  radialis  internally.  The  radial  nerve  quits  the 
artery  three  inches  above  the  wrist-joint,  and  is  not  met  with  here. 

The  Ulnar  Artery.  In  the  Middle  of  the  Forearm. — An  in- 
cision one  and  one-half  inches  long  is  made  between  the  middle 
and  inner  thirds  of  the  forearm,  through  the  skin  and  fat  down 
to  the  deep  fascia;  the  deep  fascia  is  then  incised,  and  the  artery 
is  found  lying  beneath  the  edge  of  the  flexor  carpi  ulnaris,  which 
must  be  drawn  inward  to  expose  the  vessel.  The  artery  rests  upon 
the  flexor  profundus  digitorum;  to  the  outer  side  of  the  artery  is  the 
edge  of  the  flexor  sublimis  digitorum.  The  artery  is  accompanied  by 
venae  comites,  which  lie  in  close  relation  with  it.  The  ulnar  nerve  is 
found  upon  the  inner  side  of  the  artery. 

Just  Above  the  Wrist. — The  ulnar  artery  lies  beneath  the  deep 
fascia,  with  the  tendon  of  the  flexor  carpi  ulnaris  to  its  inner  side  and 
the  tendons  of  the  flexor  sublimis  to  its  outer  side;  the  ulnar  nerve 
lies  close  to  the  inner  side  of  the  vessel  in  this  part  of  its  course. 

AMPUTATIONS,  RESECTIONS,  ETC. 

Surgical  Anatomy  of  the  Hand. — The  hand  is  composed  of  the 
carpus,  metacarpus,  and  phalanges.  Each  finger  is  made  up  of  three 
phalanges,  the  thumb  of  two  (see  Fig.  227). 

Phalango-phalangeal  Joints. — The  fingers  are  formed  by  the 
phalanges,  which  articulate  with  each  other,  end  to  end.     Upon  the 


AMPUTATIONS,  RESECTIONS,  ETC.  519 

anterior  aspect  are  found  the  flexor  tendons;  upon  the  posterior  are 
the  extensor  tendons. 

Each  phalango-phalangeal  joint  has  an  anterior  ligament  and  two 
lateral  ligaments,  the  posterior  ligament  being  formed  by  the  spread- 
out  extensor  tendon. 

Flexion  and  extension  are  permitted  in  these  joints.  Flexion 
occurs  by  the  gliding  of  the  distal  phalanx  around  the  head  of  the 
proximal,  and  therefore  when  the  finger  is  flexed  the  joint  is  found 
below  the  angle  of  the  knuckle  at  a  distance  which  corresponds  to  the 
thickness  of  the  end  of  the  proximal  bone. 

Metacarpophalangeal  Joints. — These  joints  are  quite  simi- 
lar to  the  phalango-phalangeal;  they  are  formed  by  the  articulation  of 
the  heads  of  the  metacarpal  bones  with  the  proximal  ends  of  the 
phalanges.  They  are  provided  with  an  anterior  ligament  and  two 
lateral  ligaments;  the  extensor  tendon  spreads  out  in  the  form  of  a 
broad,  fibrous  sheath  as  it  passes  across  the  posterior  aspect  of  the 
joint,  and  thus  serves  as  a  posterior  ligament,  completely  covering  the 
joint  upon  its  posterior  aspect.  The  anterior  ligaments  are  firmly 
united  with  each  other  (except  that  of  the  thumb),  so  as  to  bind  the 
heads  of  the  metacarpal  bones  firmly  together  into  one  strong,  solid 
row,  which  lends  a  great  element  of  strength  to  the  hand. 

The  lateral  ligaments  are  attached  to  the  bones,  excentrically,  in 
such  a  manner  that,  although  a  considerable  range  of  adduction  and 
abduction  is  allowed  when  the  fingers  are  extended,  this  is  not  per- 
mitted when  they  are  flexed;  when  flexion  takes  place,  the  lateral  liga- 
ments become  relatively  short,  since  the  points  to  which  they  are  fixed 
become  more  widely  separated.  "When  flexion  takes  place  between  the 
phalanx  and  the  head  of  the  metacarpal  bone,  it  is  accomplished  by 
the  proximal  end  of  the  phalanx  gliding  around  the  head  of  the  meta- 
carpal bone,  and,  therefore,  in  this  position,  the  level  of  the  joint  will 
be  found  at  a  distance  below  the  angle  of  the  knuckle  which  corre- 
sponds to  the  thickness  of  the  head  of  the  metacarpal  bone. 

EXARTICULATION   OE   THE    FlNGER   AT    THE    PHALANGO-PHALAN- 

geal  Joint. — In  amputating  a  portion  of  a  finger  an  effort  should 
be  made  to  use  what  integument  may  be  available,  with  a  view  to  pre- 
serving as  much  of  the  length  of  the  finger  as  possible.  No  doubt, 
where  one  may  choose,  the  best  amputation  is  through  a  joint  and  with 
a  long  anterior  flap;  this  brings  the  suture  line  upon  the  posterior 
aspect  of  the  stump  and  out  of  the  way  of  pressure. 

The  end  of  the  finger  which  is  to  be  amputated  is  seized  by  the 


520  UPPER  EXTREMITY. 

operator  with  the  left  hand  and  strongly  flexed,  and  a  transverse  in- 
cision, reaching  down  to  the  bone,  is  then  made  across  its  dorsal  sur- 
face, about  one-half  inch  below  the  point  of  the  knuckle;  this  incision 
should  not  include  more  than  one-half  of  the  circumference  of  the 
finger.  An  additional  incision  is  then  made  upon  either  side,  extend- 
ing from  the  end  of  the  transverse  incision,  along  the  side  of  the 
finger,  for  a  distance  corresponding  to  the  length  of  the  proposed  flap, 
and  this  should  also  penetrate  to  the  bone. 

With  the  finger  still  strongly  flexed,  the  joint  is  now  opened 
upon  its  dorsal  aspect,  remembering  that  the  line  of  the  joint  lies 
below  the  point  of  the  knuckle.  After  the  joint  has  been  opened 
the  point  of  the  knife  should  be  passed  in  on  each  side  and  the  lateral 
ligaments  freely  divided,  when  the  joint  surfaces  may  be  separated 


Pig.  225. — Exarticulation  of  the  Finger  at  the  Phalango-phalangeal  Joint. 
The  arrow  indicates  level  of  the  joint  when  the  finger  is  fixed.  Heavy  line 
indicates  the  long  anterior  flap. 


from  each  other.  The  blade  of  the  knife  is  then  introduced  between 
the  joint  surfaces  and  behind  the  bone,  between  the  bone  and  the 
anterior  flap,  and  with  a  sawing  motion  the  anterior  flap  is  cut,  with 
the  edge  of  the  knife  directed  toward  the  bone,  down  to  the  level  of 
the  next  joint,  or  until  a  flap  of  sufficient  length  is  obtained,  when 
it  is  cut  from  within  outward  by  turning  the  edge  of  the  knife  toward 
the  skin.  The  digital  arterial  branch  on  either  side  should  be  tied 
with  catgut.  The  corners  of  the  flap  may  be  rounded  off,  although 
this  is  probably  unnecessary.  The  anterior  flexor  tendons  may  be 
united  by  two  catgut  sutures  to  the  edge  of  the  extensor  tendons,  as 
this  increases  the  probability  of  a  movable,  useful  finger  stump.  The 
edges  of  the  skin  are  approximated  with  two  to  four  catgut  sutures, 
and  the  operation  is  complete. 


AMPUTATIONS,  RESECTIONS,  ETC. 


521 


EXARTICULATION  OF  THE  FlNGER  AT  THE  METACARPOPHALAN- 
GEAL Joint. — Amputation  through  the  metacarpophalangeal  joint 
may  be  done  with  or  without  the  removal  of  the  head  of  the  meta- 
carpal bone.  Eemoval  of  the  head  of  the  metacarpal  bone  allows  the 
adjoining  fingers  to  be  approximated,  thus  diminishing,  somewhat, 
the  apparent  deformity,  but  this  is  accomplished  at  the  expense  of  the 
solidity  and  strength  of  the  hand;  so  that,  in  most  cases,  especially 
in  laboring  people,  the  end  of  the  metacarpal  bone  is  better  not  re- 
moved. 

The  finger  is  seized  and  flexed  as  in  the  previous  operation,  and 
an  incision  made  upon  the  dorsal  aspect  of  the  hand,  commencing 


Fig.  226. — Exarticulation  of  the  Finger.  A,  incision  for  exarticulation  at 
the  metacarpophalangeal  joint;  B,  incision  for  amputation  of  finger  with 
excision  of  the  head  of  the  metacarpal  bone;  G  indicates  long  anterior  flap  in 
exarticulation  through  the  phalango-phalangeal  joint. 

one-half  inch  above  the  point  of  the  knuckle  and  carried  down  as 
far  as  the  level  of  the  web  of  the  finger.  This  incision  should  pene- 
trate to  the  bone,  dividing  the  skin  and  also  the  aponeurotic  expansion 
of  the  extensor  tendon.  At  the  lower  end  of  this  incision,  upon  a 
level  with  the  web  of  the  finger,  a  second  incision  is  carried  around 
the  finger,  cutting  all  the  structures,  including  the  anterior  and  poste- 
rior tendons,  down  to  the  bone. 

A  corner  of  the  flap  is  now  seized,  the  finger  being  drawn  toward 
the  opposite  side,  and  the  flap,  including  the  tendinous  expansion,  is 
stripped  away  from  the  bone  with  the  knife;  this  is  then  done,  in  a 
similar  manner,  with  the  other  remaining  half  of  the  flap. 

Now  strongly  flexing  the  finger,  the  joint,  which  is  located  a 


522  UPPER  EXTREMITY. 

good  one-half  inch  below  the  angle  of  the  knuckle,  is  opened  by  in- 
serting the  point  of  the  knife,  and  the  lateral  ligament  on  either  side 
is  then  completely  divided.  In  opening  the  joint  and  dividing  the 
lateral  ligaments  the  knife  may  be  grasped  by  the  blade,  being  thus 
held  short  and  firm.  The  bone  is  readily  dissected  out  of  the  flap,  care 
being  taken  not  to  perforate  the  integument  with  the  point  of  the 
knife. 

The  vessels  are  caught  and  tied,  usually  one  on  each  side  of  the 
flap;  the  corners  of  the  flap  may  be  rounded  off  and  the  end  of  the 
bone  covered  by  uniting  the  edges  of  the  flap  with  several  interrupted 
catgut  sutures. 

If,  in  addition,  the  distal  end  of  the  metacarpal  bone  is  to  be 
removed,  the  dorsal  incision  should  be  extended  somewhat  farther 
upward,  toward  the  wrist,  and  through  all  the  structures  down  to  the 
bone.  With  the  point  of  the  knife  the  soft  parts  are  then  separated 
from  the  bone,  and  with  a  strong  cutting  forceps  the  bone  is  divided 
about  one  inch  above  its  lower  end,  taking  care  to  cut  the  bone 
straight  across.  The  loose  lower  end  of  the  bone  is  then  seized  with 
a  toothed  bone  forceps  and  enucleated,  cutting  with  the  edge  of  the 
knife  applied  close  to  the  bone.  After  the  vessels  have  been  ligated, 
the  edges  of  the  flap  are  united  with  interrupted  catgut  sutures.  If 
the  head  of  the  metacarpal  bone  is  taken  away  it  is  not  necessary  to 
make  the  flap  so  long. 

EXARTICULATION    OF    THE    HAND    AT    THE    CARPOMETACARPAL 

Articulation. — Applicable  to  cases  of  traumatism  where  the  thumb 
can  be  saved. 

The  hand  which  is  to  be  amputated  is  seized  by  the  operator  and 
an  incision  made  which  crosses  the  palm  of  the  hand,  somewhat 
curved,  with  the  convexity  downward  toward  the  fingers;  it  com- 
mences on  the  radial  border  of  the  hand  near  the  head  of  the  meta- 
carpal bone  of  the  index  finger  and  ends  on  the  ulnar  border  of  the 
hand  near  the  base  of  the  fifth  metacarpal  bone.  The  incision  ex- 
tends through  the  soft  parts,  including  the  integument  and  palmar 
fascia,  down  to  the  flexor  tendons.  This  anterior  flap  is  reflected  up- 
ward to  the  level  of  the  carpo-metacarpal  articulation. 

Upon  the  back  of  the  hand  the  incision  extends  through  the  skin 
only,  and  passes  across  the  hand  somewhat  curved,  with  the  concavity 
downward  toward  the  fingers.  If  the  anterior  flap  is  scant,  the  poste- 
rior may  be  made  correspondingly  longer.  The  extremities  of  this 
posterior  incision  join  with  those  of  the  anterior.    The  flexor  tendons 


AMPUTATIONS,  RESECTIONS,  ETC. 


523 


on  the  front  of  the  hand  and  the  extensors  on  the  back  of  the  hand 
are  now  divided  transversely  down  to  the  bone  with  a  sharp  knife. 
The  hand  is  again  supinated  and  the  carpo-metacarpal  articulation 
opened,  working  from  the  ulnar  side  of  the  hand  toward  the  thumb. 
Care  should  be  taken  in  exarticulating  the  metacarpal  bone  of  the 
index  finger  from  the  trapezoid  not  to  injure  the  joint  between  the 
metacarpal  bone  of  the  thumb  and  the  trapezium. 


Fig.  227.  —  Palmar  Aspect  of  Right 
Hand.  CM,  outline  of  the  palmar  flap 
in  exarticulation  of  the  hand  through 
the  carpo-metacarpal  joint;  D,  incision 
for  exarticulation  of  hand  at  the  wrist- 
joint  (Dubrueil),  front  view. 


Fig.  228.  —  Dorsal  Aspect  of  Right 
Hand.  CM,  dorsal  incision  for  exar- 
ticulation of  the  hand  at  the  carpo- 
metacarpal joint;  D,  incision  for  ex- 
articulation at  the  wrist-joint  (Du- 
brueil), back  view. 


The  branches  of  the  radial  and  ulnar  arteries  must  be  clamped 
and  ligated  before  the  tourniquet  is  removed. 

The  edges  of  the  flaps  are  brought  together  with  interrupted 
catgut  sutures,  the  stump  being  thus  covered  by  the  strong  palmar 
integument,  and  the  suture  line  upon  the  posterior  edge  of  the 
stump  free  from  pressure,  etc. 


524 


UPPER  EXTREMITY. 


If  the  condition  of  the  integument  of  the  palm  of  the  hand  is 
such  that  the  longer  flap  cannot  be  taken  from  this  part  of  the 
hand,  then  one  may  get  a  sufficiently  long  flap  from  the  posterior 
surface,  or  two  flaps  of  equal  length,  one  from  the  anterior  and  one 
from  the  posterior  surface  of  the  hand  may  be  made. 

Surgical  Anatomy  of  the  Wrist-joint. — The  wrist-joint  is  formed 
of  the  first  row  of  the  carpal  bones  in  order,  from  without  inward, 
scaphoid,  semilunar,  and  cuneiform,  and  of  the  lower  extremities  of 
the  radius  and  ulna. 

The  three  carpal  bones  are  united  to  each  other,  and  present 


Pig.   229.— Stump  Result  of  Exarticulation  of  the  Hand  at  the 
Carpo-metacarpal  Joint. 


one  continuous  surface,  smooth,  covered  with  articular  cartilage, 
and  convex  from  side  to  side  and  from  before  backward.  The  outer 
extremity  of  this  surface  slopes  downward  to  a  much  lower  level 
than  the  inner  extremity. 

The  articular  surface  presented  by  the  lower  ends  of  the  radius 
and  ulna  is  concave  in  order  to  accommodate  the  convex  articular 
surface  of  the  upper  row  of  carpal  bones.  This  radio-ulnar  articular 
surface  is  directed  obliquely  downward  externally,  so  that  the  outer, 
or  radial,  end  is  a  considerable  distance  below  the  level  of  the  inner, 
or  ulnar,  end,  and  is  continued  into  the  external  styloid  process,  to 
the  tip  of  which  the  external  lateral  ligament  is  attached;  the  inner, 


AMPUTATIONS,  RESECTIONS,  ETC.  525 

or  ulnar,  side  of  this  radio-ulnar  articular  surface  presents  the  inner 
styloid  process,  prolonged  from  the  lower  end  of  the  ulna.  The  tip 
of  this  process  gives  attachment  to  the  internal  lateral  ligament  of 
the  wrist-joint. 

Of  the  three  carpal  hones,  the  outer  two,  the  scaphoid  and 
semilunar,  correspond  to  and  articulate  with  the  radial  articular 
surface;  the  inner,  the  cuneiform,  corresponds  to  the  ulnar  articular 
surface,  an  interarticular  fibro-cartilage  being  interposed  between 
them. 

There  is  a  broad  anterior  and  a  broad  posterior  ligament,  and 
these,  together  with  the  lateral  ligament  on  either  side,  practically 
form  a  capsular  ligament,  which  is  lined  upon  its  inner  aspect  by  a 
thin,  serous  layer,  the  synovial  membrane  of  the  joint. 

BXAETICULATION     OF    THE    HAND    AT    THE    WRIST-JOINT     (Du- 

jbrueil). — An  assistant  steadies  the  forearm,  drawing  the  integument 
rather  toward  the  elbow.  The  hand  which  is  to  be  amputated  is 
seized  by  the  operator,  and  commencing  upon  the  front  of  the  wrist, 
between  the  middle  and  outer  thirds,  an  incision  is  made,  which  is 
carried  inward  around  the  inner  border  of  the  wrist,  below  the  level 
of  the  styloid  process,  and  across  the  back  of  the  wrist,  terminating 
at  a  point  between  the  middle  and  outer  thirds  and  directly  opposite 
the  point  where  the  incision  commenced.  This  incision  should  ex- 
tend through  the  skin  and  subcutaneous  fatty  tissue  and  should  be 
placed  well  below  the  level  of  the  wrist-joint;  otherwise,  after  the 
integument  has  retracted,  the  cut  edge  will  be  found  to  be  above 
the  level  of  the  wrist-joint. 

A  tongue-shaped  flap,  with  its  base  corresponding  to  the  radial 
third  of  the  circumference  of  the  wrist,  is  now  marked  out  by  an 
incision  reaching  from  either  end  of  the  circular  incision  described 
above.  This  flap  of  integument  is  taken  from  over  the  metacarpal 
bone  of  the  thumb,  its  lower  extremity  corresponding  to  the  meta- 
carpo-phalangeal  articulation  of  the  thumb  (see  Fig.  227).  This  flap, 
including  the  superficial  fascia  and  fat,  is  dissected  back  to  the  level 
of  the  wrist-joint.  The  wrist-joint  is  then  entered  by  introducing 
the  blade  of  the  knife  into  the  joint  on  its  radial  side,  below  the 
styloid  process,  and  the  hand  severed  from  the  forearm,  thus  com- 
pleting the  exarticulation. 

The  radial  and  ulnar  arteries  are  picked  up  and  ligated,  the 
median  and  ulnar  nerves  seized  and  cut  short,  and  the  ends  of  the 
bones  covered  over  with  the  flap,  which  is  fixed  with  interrupted 


526  UPPER  EXTREMITY. 

catgut  sutures.  The  first  stitch  should  unite  the  apex  of  the  tongue- 
shaped  flap  to  the  skin  at  a  point  corresponding  to  the  tip  of  the 
styloid  process  of  the  ulna,  and  the  other  stitches  are  then  placed 
so  as  to  distribute  the  flap  evenly,  should  it  be  found  to  be  a  little 
redundant. 

An  analogous  operation  may  be  done  at  the  wrist-joint,  taking 
the  tongue-shaped  flap  of  integument  from  the  ulnar  side  of  the 
hand. 

One  may  also  exarticulate  at  the  wrist-joint,  using  two  flaps, 
an  anterior  and  a  posterior  flap,  of  equal  length;  or  else  one  long, 
preferably  the  anterior,  and  one  short;  or  the  circular  method  may  be 
used. 

Amputation  through  the  Forearm. — The  forearm  is  a  good  place 
at  which  to  practice  the  old  musculo-tegumentary  flap  method. 
Practically,  this  method  is  now  almost  entirely  discarded  in  favor 
of  the  skin  flap  or  circular  method.  The  arm  overhangs  the  edge 
of  the  table.  The  hand,  which  is  supinated,  is  supported  by  an 
assistant.  A  long,  sharp  amputating  knife  is  introduced  through 
the  skin  upon  the  outer  side  of  the  forearm,  at  the  level  where  it 
is  intended  to  divide  the  bones,  until  its  point  touches  the  outer 
surface  of  the  radius;  it  is  then  pushed  through  the  soft  parts  upon 
the  front  of  the  forearm,  keeping  close  to  the  anterior  surface  of  the 
bones,  and  emerging  at  a  corresponding  point  upon  the  inner,  or 
ulnar,  side  of  the  forearm.  Now,  with  a  sawing  motion  and  with 
the  edge  of  the  knife  directed  toward  the  radius  and  ulna,  the  ante- 
rior flap  which  includes  the  integument  and  all  the  muscular  tissue, 
is  cut  away  from  the  bones.  If  the  anterior  and  posterior  flaps  are 
to  be  of  equal  length,  each  flap  should  correspond  in  length  to  one- 
half  the  diameter  of  the  limb,  at  the  point  where  the  bones  are  to 
be  divided,  plus  one-third  extra,  which  is  allowed  for  retraction. 
When  the  flap  has  been  cut  to  a  sufficient  length,  the  edge  of  the 
knife  is  turned  toward  the  integument  and  the  flap  cut  square  from 
within  outward. 

The  posterior  flap  is  formed  in  a  similar  manner.  The  point  of 
the  knife  is  again  introduced  upon  the  outer,  or  radial,  side  of  the 
forearm  in  the  upper  angle  of  the  incision  which  marks  the  anterior 
flap,  and  thrust  through  the  forearm  behind  the  bones,  between  them 
and  the  soft  parts,  emerging  at  the  upper  part  of  the  incision  upon 
the  inner,  or  ulnar,  side  of  the  forearm,  and  then,  with  the  edge  of 
the  knife  closely  applied  to  the  bones,  the  posterior  flap  is  cut  equal 


AMPUTATIONS,  RESECTIONS,  ETC.  527 

in  length  to  the  anterior.  The  flaps  should  be  square,  and  not 
tongue-shaped. 

The  flaps  are  turned  hack  and  held  thus  by  the  hands  of  an 
assistant  or  with  sharp  retractors,  or  by  the  operator.  With  a  scalpel 
the  interosseous  membrane  is  cut  through  and  the  bones  cleaned  of 
any  remaining  soft  parts,  in  order  to  make  way  for  the  saw. 

The  heel  of  the  saw  is  placed  upon  one  of  the  bones,  and  by 
drawing  it  backward  firmly  and  steadily  a  groove  is  made,  after  which 
the  bones  can  be  rapidly  severed,  engaging  the  second  bone  after 
the  first  has  been  partly  sawn  through,  and  completing  the  section 
of  both  simultaneously.  No  cloth  retractor  is  necessary,  the  flaps 
being  held  back  by  the  operator's  hand  while  he  saws  through  the 
bones. 

In  the  dead  subject  it  will  be  seen  that  the  muscles  in  the  flap 
protrude  beyond  the  edge  of  the  integument;  this  is  due  to  the  un- 
equal retraction  of  skin  and  muscle,  and  does  not  occur  to  the  same 
degree  in  the  living  subject.  Should  the  ends  of  the  muscles  or  ten- 
dons protrude,  they  may  be  trimmed  off  with  the  scissors. 

The  radial  and  ulnar  arteries  are  sought  for  and  ligated;  also 
the  anterior  and  posterior  interosseous.  These  latter  are  found  close 
to  the  anterior  and  posterior  surfaces,  respectively,  of  the  interos- 
seous membrane.  The  median  and  ulnar  nerves  should  be  drawn 
down  and  cut  short.  The  edges  of  the  flap  are  joined  all  around 
with  interrupted  catgut  sutures. 

We  may  amputate  through  the  forearm,  using  skin  flaps,  ante- 
rior and  posterior,  of  equal  length,  or  one  long  and  the  other  short; 
or  we  may  reflect  a  circular  tegumentary  cuff,  in  all  of  these  opera- 
tions, dividing  the  muscles  on  a  level  with  or  just  below  the  point 
at  which  the  bones  are  to  be  divided. 

Surgical  Anatomy  of  the  Elbow-joint.  —  The  elbow-joint  is  an 
irregular,  rather  complicated  joint,  formed  by  the  lower  end  of  the 
humerus  and  the  upper  end  of  the  radius  and  ulna. 

The  lower  end  of  the  humerus  is  broad  from  side  to  side  and 
flattened  from  before  backward,  and  presents  below  two  partially 
separated,  smooth,  rounded,  articular  surfaces,  the  smaller,  outer 
one  being  for  articulation  with  the  radius,  and  the  broader,  inner 
one  for  articulation  with  the  ulna.  The  plane  of  this  double  artic- 
ular surface  is  oblique  from  without  downward  and  inward,  its  inner 
end  being  on  a  much  lower  level  than  its  outer. 

The  surface  for  articulation  with  the  radius,  the  external,  is  a 


528  UPPER  EXTREMITY. 

portion  of  a  sphere,  and  occupies  the  lower  and  anterior  aspect  of 
the  humerus. 

The  surface  with  which  the  ulna  articulates,  the  inner,  is  broad, 
spool-shaped,  and  occupies  not  only  the  anterior  and  inferior,  but 
also  the  posterior,  aspect  of  the  bone.  This  portion  articulates  with 
the  greater  sigmoid  cavity  of  the  ulna. 

Below,  the  joint  is  formed  by  the  upper  end  of  the  radius  ex- 
ternally and  the  upper  end  of  the  ulna  internally.  The  upper  end 
or  head  of  the  radius  presents  a  shallow  cup-shaped  surface,  covered 
with  cartilage  for  articulation  with  the  radial  part  of  the  articular 
surface  of  the  humerus;  this  surface  is  surrounded  by  a  smooth, 
narrow  margin,  which  rotates  within  the  ring  formed  by  the  lesser 
sigmoid  cavity  of  the  upper  end  of  the  ulna  and  the  orbicular  liga- 
ment. 

The  head  of  the  radius  lies  just  below  the  external  condyle,  and 
may  be  recognized  even  when  the  joint  is  considerably  swollen;  by 
supinating  and  pronating  the  hand  it  may  be  felt  to  rotate  beneath 
the  skin.  The  elbow-joint  is  readily  entered  between  the  head  of 
the  radius  and  the  external  condyle. 

The  upper  extremity  of  the  ulna  is  irregular,  and  presents  an 
articular  surface,  the  greater  sigmoid  cavity,  which  is  made  up  of 
the  superior  surface  of  the  upper  end  of  the  ulna  and  the  anterior 
surface  of  the  olecranon  process.  The  olecranon  is  a  strong,  square- 
shaped  process  of  bone  which  projects  upward  from  the  posterior 
part  of  the  upper  end  of  the  ulna.  The  greater  sigmoid  cavity  is 
covered  by  articular  cartilage  and  articulates  with  the  trochlear  sur- 
face of  the  lower  end  of  the  humerus.  The  upper  end  of  the  ulna 
further  presents,  upon  its  outer  edge,  a  smooth  depression,  the  lesser 
sigmoid  cavity,  to  either  end  of  which  the  orbicular  ligament  is 
attached.  Within  the  ring  formed  by  the  orbicular  ligament  and 
the  lesser  sigmoid  cavity  the  upper  end  of  the  radius  rotates  in 
pronation  and  supination. 

Besides  the  parts  entering  directly  into  the  formation  of  the 
elbow-joint  there  may  be  felt,  internally,  the  internal  epicondyle, 
very  prominent  and  giving  attachment,  upon  its  anterior  aspect,  to 
the  common  tendon  of  origin  of  the  flexor  muscles  of  the  forearm, 
and,  externally,  the  less  prominent  external  epicondyle,  giving  at- 
tachment, upon  its  posterior  aspect,  to  the  common  tendon  of  the 
extensor  muscles  of  the  forearm.  Behind  may  be  felt  the  prominent 
olecranon  process.    At  its  junction  with  the  ulna  the  olecranon  proc- 


AMPUTATIONS,  RESECTIONS,  ETC.  529 

ess  is  somewhat  constricted,  and  is  here  often  the  site  of  fracture. 
Its  anterior  surface  enters  into  the  formation  of  the  elbow-joint, 
forming  the  upper  part  of  the  greater  sigmoid  cavity.  Its  posterior 
surface  is  subcutaneous  and  triangular  in  shape,  with  its  apex  below, 
where  it  is  continuous  with  the  posterior  border  of  the  shaft  of  the 
ulna.  To  the  broad,  upper  border  of  the  olecranon  process  is  at- 
tached the  triceps  tendon,  and  around  its  margin  the  posterior  and 
lateral  ligaments  of  the  joint.  The  upper  border,  or  surface,  of  the 
olecranon  process,  when  the  arm  is  extended,  is  on  a  line  drawn  be- 
tween the  two  epicondyles. 

The  elbow-joint  is  provided  practically  with  a  capsular  liga- 
ment, which  is  lined,  upon  its  inner  surface,  by  a  synovial  membrane 
which  also  dips  into  that  part  of  the  joint  between  the  head  of  the 
radius  and  the  lesser  sigmoid  cavity  of  the  ulna  and  orbicular  liga- 
ment. 

The  ulnar  nerve  lies  in  close  relation  with  the  elbow-joint,  poste- 
riorly, in  a  groove  between  the  internal  epicondyle  and  the  olecranon 
process. 

ExARTICULATION     OF     THE      FOREARM     AT      THE      ELBOW-JOINT 

(Double  Circular  Method). — The  arm  overhangs  the  side  of  the 
table,  and  is  steadied  by  an  assistant,  who  draws  the  integument 
somewhat  toward  the  shoulder-joint.  The  operator  grasps  the  limb 
with  the  left  hand,  and  with  a  long  amputating  knife  a  circular  in- 
cision is  made  around  the  forearm,  through  the  skin  and  fat  down 
to  the  deep  fascia.  This  incision  should  be  placed  below  the  level 
of  the  elbow-joint  a  distance  corresponding  to  one-half  the  diameter 
of  the  arm  at  the  elbow-joint,  plus  one-third  extra,  which  is  allowed 
for  shrinkage  of  the  skin.  The  upper  surface  of  the  head  of  the 
radius  marks  the  level  of  the  elbow-joint.  This  tegumentary  flap  is 
dissected  away  from  the  deep  fascia  and  reflected  upward  like  a 
turned-up  cuff  as  far  as  the  level  of  the  elbow-joint.  At  this  level 
the  muscles  are  divided  with  the  long  knife  down  to  the  bone,  and 
the  elbow-joint  then  entered  externally  above  the  head  of  the  radius, 
finally  passing  in  between  the  ulna  and  the  humerus,  cutting  the 
anterior  and  lateral  ligaments.  The  forearm  then  hangs  suspended 
by  the  attachment  of  the  triceps  tendon,  and,  this  being  cut  close  to 
the  olecranon,  the  exarticulation  is  complete. 

In  this  operation  a  common  fault  is  that  the  muscles,  being  cut 
on  a  level  with  the  elbow-joint,  retract  and  leave  the  end  of  the 
humerus  projecting  into  the  wound.    Even  if  the  muscles  are  divided 


530  UPPER  EXTREMITY. 

a  considerable  distance  below  the  level  of  the  joint  and  stripped 
away  from  the  bone  from  a  point  below  the  level  of  the  joint,  it  helps 
but  little,  as,  upon  the  posterior  aspect,  there  are  no  muscles,  and 
even  the  tendon  of  the  triceps,  when  cut  close  to  the  olecranon,  lies 
well  above  the  level  of  the  joint;  therefore,  in  most  cases,  it  is  de- 
sirable to  supplement  this  operation  by  resecting  the  lower  articular 
end  of  the  humerus,  which  may  be  readily  done.  As  regards  the 
usefulness  of  the  resulting  stump,  it  matters  little  if  we  make  the 
section  just  above,  instead  of  through,  the  elbow-joint. 

It  is  necessary  to  ligate  the  brachial  artery  and  its  accompanying 
vein  separately.  The  median,  ulnar,  and  musculo-spiral  nerves  are 
drawn  down  and  cut  short.  The  edges  of  the  skin  are  united  from 
side  to  side  with  interrupted  catgut  sutures,  and  a  small  drain  intro- 
duced, which  may  be  removed  after  forty-eight  hours. 

Amputation  of  the  Arm. — Here  the  double  circular  method  is 
preferable.  The  arm,  hanging  over  the  side  of  the  table,  is  grasped 
above,  near  the  shoulder,  by  an  assistant,  who,  at  the  same  time  that 
he  steadies  the  arm,  draws  the  integument  somewhat  toward  the 
shoulder.  With  a  long  amputating  knife  a  circular  incision  is  made, 
which  reaches  through  the  skin  and  superficial  fascia  down  to  the 
deep  fascia.  This  incision  should  be  placed  below  the  level  at  which 
the  bone  is  to  be  divided  a  distance  equal  to  one-half  the  diameter 
of  the  arm,  plus  one-third,  which  is  allowed  for  retraction  of  the 
skin. 

The  circular  flap,  which  includes  all  the  fatty  tissue,  but  not  the 
deep  fascia,  is  now  dissected  back  like  a  cuff  to  a  point  one  inch 
below  the  level  at  which  the  bone  is  to  be  divided;  at  this  point 
the  muscles  are  severed  down  to  the  bone  with  one  circular  sweep 
of  the  long  knife. 

With  a  blunt  elevator  or  the  back  of  the  scalpel  the  muscles, 
but  not  the  periosteum,  are  separated  from  the  humerus  for  another 
inch,  and  thus  the  level  is  reached  at  which  the  bone  is  to  be  divided. 
After  the  periosteum  has  been  cut  by  drawing  the  knife  around  the 
bone,  the  heel  of  the  saw  is  applied  and  with  a  firm  backward  move- 
ment a  groove  is  made  in  which  the  saw  may  work,  and  then  the  bone 
is  rapidly  severed. 

While  sawing  the  bone  it  is  unnecessary  to  use  a  cloth  retractor, 
as  the  soft  parts  may  be  held  back  so  as  to  give  the  saw  freedom,  by 
the  hands  of  an  assistant,  or  with  two  sharp  retractors. 

Having  completed  the  amputation,  it  will  be  seen  that  the  mus- 


AMPUTATIONS,  RESECTIONS,  ETC. 


531 


cles  slightly  overhang  the  end  of  the  bone  without  covering  it,  and 
that  the  skin  flap  is  sufficiently  long  to  cover  the  whole  stump. 

The  brachial  artery  and  accompanying  veins  are  found  lying 
anterior  and  internal  to  the  bone,  and  should  be  clamped  and  tied; 


Fig.  230.— Right  Arm,  Anterior  Aspect.  A,  outline  of  the  lateral  deltoid 
flap  in  exarticulation  at  the  shoulder-joint;  B,  amputation  through  the  arm; 
1,  incision  through  the  skin;  2,  incision  through  the  muscle;  3,  line  of  division 
through  the  bone;  C,  incision  for  exarticulation  through  the  elbow-joint 
(circular  method). 


the  median  and  ulnar  nerves,  which  are  in  close  proximity  to  the 
brachial  artery,  should  be  cut  short;  likewise  the  musculo-spiral, 
which  is  found  upon  the  posterior  surface  of  the  humerus.  The  supe- 
rior profunda,  a  branch  of  the  brachial  artery,  which  accompanies  the 


532  UPPER  EXTREMITY. 

musculo-spiral  nerve,  is  also  seized  and  ligated.  The  tourniquet  is 
then  removed  and  any  remaining  bleeding  vessels  clamped  and 
ligated. 

The  edges  of  the  skin  are  united  from  side  to  side,  making  a 
transverse  line,  by  several  interrupted  catgut  sutures;  if  the  wound 
is  clean,  one  may  omit  drainage,  or  a  temporary  drain  may  be  intro- 
duced, and  removed  after  forty-eight  hours. 

The  arm  may  also  be  amputated  with  the  formation  of  musculo- 
tegumentary  flaps,  as  described  for  the  forearm,  or,  instead  of  a  cuff 
skin  flap,  one  may  use  lateral  or  antero-posterior  skin  flaps  of  equal 
length,  or  one  long  and  the  other  short. 

Surgical  Anatomy  of  the  Shoulder- joint.  —  The  shoulder- joint 
consists  of  the  articulation  of  the  upper  end  of  the  humerus  and  the 
glenoid  cavity  of  the  scapula.  The  articular  surface  of  the  upper 
end  of  the  humerus  looks  inward  and  backward  and  is  hemispheroidal 
in  shape;  it  presents  the  arc  of  a  smaller  sphere  from  before  back- 
ward, and  of  a  larger  sphere  from  above  downward;  that  is,  the 
diameter  from  before  backward  is  shorter  than  that  from  above 
downward. 

The  articular  surface  is  limited  by  the  anatomical  neck,  which 
is  narrow  and  well  marked  above,  but  broad  and  less  well  marked 
below;  the  anatomical  neck  marks  the  junction  of  the  head  of  the 
bone  with  the  shaft. 

Externally  may  be  observed  the  broad,  large  tuberosity  major; 
internally  and  below  the  head  is  the  smaller  tuberosity,  the  tuber- 
osity minor.  To  the  tuberosity  minor  is  attached  the  tendon  of  one 
muscle,  the  subscapularis;  to  the  tuberosity  major — i.e.,  to  its  upper 
and  posterior  borders — are  attached  the  tendons  of  three  muscles: 
the  supraspinatus,  the  infraspinatus,  and  the  teres  minor,  in  that 
order  from  above  downward. 

The  anterior  border  of  the  greater  tuberosity  forms  the  exter- 
nal border  of  the  bicipital  groove,  the  external,  or  anterior,  bicipital 
ridge;  the  lesser  tuberosity  and  the  ridge  that  is  prolonged  down- 
ward from  it  forms  the  inner  border  of  the  bicipital  groove,  the  in- 
ternal, or  posterior,  bicipital  ridge.  Between  the  two  is  the  bicipital 
groove. 

To  the  external  bicipital  ridge  is  attached  the  tendon  of  the 
pectoralis  major;  to  the  internal  bicipital  ridge  are  attached  the 
tendons  of  the  latissimus  dorsi  and  teres  major.  Lying  in  the  groove 
itself,  held  in  place  by  a  process  of  fibrous  tissue,  is  the  long  tendon 


AMPUTATIONS,  RESECTIONS,  ETC.  533 

of  the  biceps  muscle.  Close  to  the  humerus,  between  the  tendon  of 
the  pectoralis  major  in  front  and  the  tendons  of  the  latissimus  dorsi 
and  teres  major  behind,  are  the  brachial  vessels  and  accompanying 
nerves,  which  descend  in  a  bunch  from  the  axilla,  partially  overlapped 
by  the  coraco-brachialis  muscle.  The  bicipital  groove  really  forms 
the  outer  wall  of  the  axilla  when  the  arm  hangs  by  the  side. 

Below  the  tuberosities  is  the  surgical  neck,  so  called  because  it 
is  a  rather  common  site  of  fracture. 

The  glenoid  cavity,  a  depressed  area  upon  the  head  of  the  scap- 
ula, is  much  less  extensive  in  area  than  the  articular  surface  pre- 
sented by  the  humerus;  it  is  shallow,  longer  from  above  downward 
than  from  before  backward,  and  is  connected  with  the  body  of  the 
scapula  by  the  neck. 

The  glenoid  cavity  presents  a  slightly  raised  margin,  to  which 
margin  is  attached  the  glenoid  ligament,  which  serves  to  deepen  the 
cavity. 

Overhanging  the  shoulder-joint  is  the  acromion  process,  the 
extreme  outer  end  of  the  spine  of  the  scapula;  this  process  articulates 
with  the  outer  end  of  the  clavicle,  and  forms  the  prominent  outer 
part  of  the  shoulder-girdle  and  a  protecting  ledge  over  the  shoulder- 
joint. 

In  front  and  internal  to  the  shoulder- joint  the  coracoid  process 
may  be  felt,  and  in  thin  subjects  seen;  it  projects  forward  from  the 
upper  border  of  the  scapula,  lying  below  the  outer  end  of  the  clavicle, 
to  the  under  surface  of  which  it  is  connected  by  strong  ligaments. 
Passing  from  the  coracoid  to  the  acromion  process  is  a  strong  liga- 
mentous band,  the  coraco-acromial  ligament.  This  ligament  passes 
over  the  head  of  the  humerus,  across  the  upper  part  of  the  shoulder- 
joint,  deepening  the  cavity  in  which  the  head  of  the  humerus  plays 
and  serving  to  add  strength  to  the  joint. 

The  shoulder-joint  is  provided  with  a  capsular  ligament,  which 
is  attached  above  to  the  neck  of  the  scapula  around  the  glenoid 
cavity,  and  below  to  the  anatomical  neck  of  the  humerus.  A  sepa- 
rate fibrous  band,  called  the  coraco-humeral  ligament,  extends  from 
the  coracoid  process  down  to  the  neck  of  the  humerus,  where  it  is 
attached  in  common  with  the  capsular  ligament,  of  which  it  is  really 
a  part. 

The  long  tendon  of  the  biceps  is  attached  to  the  upper  margin 
of  the  glenoid  cavity;  it  passes  across  the  upper  surface  of  the  head 
of  the  humerus,  through  the  shoulder-joint,  and  emerges  through 


534  UPPER  EXTREMITY. 

the  anterior  part  of  the  capsule,  and  then  passes  down  the  arm,  being 
lodged  in  the  bicipital  groove.  In  its  course  through  the  shoulder- 
joint  the  long  tendon  of  the  biceps  is  entirely  enveloped  in  a  tubular 
process  of  the  synovial  membrane,  and  thus,  although  it  passes 
through  the  shoulder-joint,  the  tendon  is  at  the  same  time  excluded 
from  it. 

Like  a  hood  or  cushion,  the  deltoid  muscle  covers  and  serves  to 
protect  the  shoulder-joint;  beneath  the  deltoid  there  is  a  bursa, 
which  sometimes  becomes  diseased. 

Below  the  acromion  and  beneath  the  deltoid  muscle  the  head  of 
the  humerus  may  be  readily  recognized.  It  may  be  felt  to  rotate 
underneath  the  soft  parts  upon  manipulation.  It  is  responsible  for 
the  rounded  contour  of  the  shoulder;  if  the  head  of  the  humerus 
leaves  the  glenoid  cavity,  the  shoulder  presents  a  peculiar  flattened 
appearance,  which  is  very  striking,  and  the  sharp  outer  end  of  the 
acromion  process  becomes  especially  prominent  and  tends  to  direct 
attention  to  the  fact  that  the  head  of  the  humerus  has  been  dis- 
located. 

ExARTICULATION     AT     THE     SHOULDER-JOINT     (SpENOE). The 

shoulder  should  overhang  the  edge  of  the  table  and  the  arm  should 
be  abducted  a  little  from  the  side  of  the  thorax  and  at  the  same  time 
rotated  somewhat  outward,  so  that  the  great  tuberosity  is  directed 
outward. 

The  incision  is  about  six  inches  long,  and  commences  above,  at 
the  clavicle,  between  the  acromion  and  coracoid  processes,  and  passes 
down  the  front  of  the  arm  as  far  as  the  point  where  the  deltoid  is 
attached  to  the  humerus.  This  incision  is  deep,  penetrating  through 
the  skin,  fascia,  and  muscle  down  into  the  bicipital  groove.  "With 
the  long  knife  a  circular  incision  is  then  made  around  the  arm,  on 
a  level  with  the  lower  end  of  the  longitudinal  incision;  this  incision, 
upon  the  inner  aspect  of  the  arm,  should  pass  through  the  integu- 
ment and  superficial  fascia  (subcutaneous  fat)  only,  care  being  taken 
not  to  sever  the  brachial  vessels;  for  the  rest  of  the  circumference 
of  the  arm,  however,  this  circular  incision  penetrates  through  all  the 
soft  parts  to  the  bone. 

The  outer  edge  of  the  wound  is  seized,  and  with  a  scalpel  the 
soft  parts  are  dissected  away  from  the  outer  surface  of  the  humerus, 
the  arm  being  rotated  inward  by  the  assistant,  to  facilitate  this  step 
of  the  operation. 

The  capsular  ligament  being  now  exposed,  the  joint  should  be 


AMPUTATIONS,  RESECTIONS,  ETC. 


535 


opened;  this  is  done,  not  by  passing  the  blade  of  the  knife  flatwise 
between  the  head  of  the  humerus  and  the  acromion  process,  but  by 
cutting  directly  down  upon  the  upper  surface  of  the  head  of  the  hu- 
merus, from  behind  forward,  as  though  one  would  cut  into  the  head 
of  the  bone.  During  this  step  of  the  operation  the  assistant  may  help 
by  rotating  the  arm  first  inward  and  then  outward.  In  this  way  the 
joint  is  freely  opened,  the  long  tendon  of  the  biceps  being  cut  at  the 


Fig.  231. — Right  Shoulder,  Anterior  View.  R,  line  of  incision  for  resec- 
tion of  shoulder- joint;  8,  incision  for  exarticulation  at  the  shoulder-joint 
(Spence). 


same  time.  The  head  of  the  bone  is  now  turned  out  of  its  socket 
and  drawn  forcibly  outward,  away  from  the  glenoid  cavity;  the  long 
knife  is  introduced  into  the  wound,  behind  the  head  of  the  humerus, 
and  the  soft  parts,  with  the  edge  of  the  knife  applied  close  to  the 
surface  of  the  bone,  are  separated  from  the  inner  aspect  of  the 
humerus  to  a  point  a  little  below  the  level  of  the  circular  incision, 
care  being  taken  not  to  injure  the  brachial  vessels,  which  run  parallel 


536  UPPER  EXTREMITY. 

with  the  inner  surface  of  the  humerus,  and  which  have  not,  as  yet, 
been  divided. 

Now,  with  a  final  stroke  of  the  knife,  the  operation  is  completed 
by  cutting  through  the  soft  parts  upon  the  inner  aspect  of  the  arm 
down  to  the  surface  of  the  bone,  thus  severing  the  vessels  and  nerves. 
Just  before  this  final  cut  which  divides  the  vessels  is  made  an  as- 
sistant grasps  the  mass  of  soft  parts  which  have  been  separated  from 
the  inner  side  of  the  humerus  and  which  include  the  brachial  vessels, 
and  thus  compresses  them  while  they  are  being  cut,  and  continues 
to  hold  them  until  the  operator  can  secure  the  divided  vessels  with 
artery  forceps,  after  which  they  are  tied.  Other  vessels  which  spurt 
are  clamped  and  tied  as  the  operation  progresses. 

The  edges  of  the  skin  may  be  brought  together  with  interrupted 
catgut  sutures,  a  drain  emerging  from  the  lower  end  of  the  wound 
and  left  in  place  for  forty-eight  to  seventy-two  hours;  or  the  edges 
of  the  wound  may  be  closed  throughout  and  an  opening  made 
through  the  posterior  part  of  the  flap,  near  the  glenoid  cavity,  and 
the  wound  thus  drained.     This  latter  plan  is  very  satisfactory. 

The  above  is  a  good  method  for  exarticulation  at  the  shoulder- 
joint,  which  may  thus  be  accomplished  with  the  loss  of  but  little 
blood.  Through  the  longitudinal  incision,  which  is  first  made,  the 
joint  may  be  opened  and  freely  explored  and  drained,  or  the  joint 
may  be  excised;  this  is  a  great  advantage,  as  we  are  often  in  doubt 
as  to  the  necessity  of  exarticulation  until  after  the  joint  has  been 
opened  and  inspected. 

Exarticulation  at  the  Shoulder-joint  with  an  Esmarch 
Bandage  Applied. — The  shoulder  overhanging  the  side  of  the  table 
and  the  arm  somewhat  abducted,  an  Esmarch  bandage  or  rubber  tube 
is  applied  tightly  about  the  axilla,  passing  around  the  shoulder  over  the 
outer  part  of  the  clavicle.  With  a  long  knife  a  circular  incision  is 
then  made  through  the  integument  and  fat  down  to  the  deep  fascia. 
This  incision  should  be  placed  just  above  the  insertion  of  the  deltoid 
muscle.  The  integument,  which  retracts  at  once,  is  drawn  toward 
the  shoulder  by  an  assistant,  and  the  muscles,  vessels,  etc.,  divided 
by  a  second  circular  sweep  of  the  long  knife  down  to  the  bone  as 
high  up  as  the  retracted  integument  permits;  the  bone  is  then  sawn 
through  at  this  level.  The  brachial  artery  and  accompanying  veins 
are  now  clamped  and  tied;  also  the  superior  profunda,  which  is  found 
upon  the  back  side  of  the  humerus  in  company  with  the  musculo- 
spiral  nerve. 


AMPUTATIONS,  RESECTIONS,  ETC. 


537 


After  these  vessels  have  been  tied  the  Esmarch  bandage  is  re- 
moved and  any  further  spurting  vessels  ligated. 

A  second  incision  is  now  made  from  the  acromion  process  down 
upon  the  front  of  the  stump  of  the  humerus  and  penetrating  to  the 
bone.    The  soft  parts  are  then  cut  away  from  the  outer  surface  of 


Fig.  232.— Right  Shoulder,  Posterior  View.     Outline  of  the  lateral  deltoid 
flap  for  exarticulation  at  the  shoulder-joint. 


the  stump  of  the  humerus,  tying  vessels  as  they  are  cut,  and  the 
joint  opened  by  incising  the  capsule  from  behind  forward,  including 
the  tendon  of  the  biceps;  the  head  of  the  bone  is  then  turned  out 
of  its  socket,  and  while  it  is  drawn  forcibly  outward,  away  from 
the  glenoid  cavity,  the  soft  parts  upon  its  inner  side  are  stripped 
away  from  the  bone  and  the  operation  thus  completed.     But  little 


538 


UPPER  EXTREMITY. 


blood  is  lost.     The  wound  may  be  treated  as  in  the  preceding  oper- 
ation. 

After  the  circular  incision  has  been  made  through  the  soft  parts, 
including  the  muscles,  brachial  vessels,  etc.,  down  to  the  bone,  and 
while  the  tourniquet  is  still  applied  and  without  sawing  through  the 
bone,  one  may  ligate  the  vessels  and  then,  after  removing  the  tourni- 
quet, proceed  to  complete  the  operation  by  turning  the  head  of  the 


Fig.  233.— Left  Shoulder,   Side  View.     Outline  of  the  lateral  deltoid 
flap  for  exarticulation  at  the  shoulder-joint. 


bone  out  of  its  socket  and  stripping  the  soft  parts  away  from 
the  upper  part  of  the  bone  through  the  longitudinal  incision  as  de- 
scribed above.  This  would  save  sawing  through  the  shaft  of  the 
humerus. 

Exarticulation  at  the  Shoulder-joint  with  the  Forma- 
tion of  a  Lateral  Deltoid  Flap. — The  position  of  the  patient  is  the 
same  as  in  the  previous  operation,  the  shoulder  overhanging  the  edge 
of  the  table.    A  large  musculo-tegumentary  flap,  U-shaped  and  corre- 


AMPUTATIONS,  RESECTIONS,  ETC.  539 

sponding  to  the  deltoid  muscle,  is  taken  from  the  outer  aspect  of 
the  arm.  The  incision  commences  anteriorly,  just  external  to  the 
coracoid  process,  and  passes  down  upon  the  front  of  the  arm  to  a 
point  a  short  distance  above  the  insertion  of  the  deltoid  muscle, 
whence  the  incision  is  carried  backward  across  the  outer  aspect  of 
the  arm  and  then  upward  as  far  as  the  spine  of  the  scapula  to  a  point 
just  posterior  to  the  acromion  process;  this  incision  reaches  to  the 
bone  throughout  its  whole  course.  In  dividing  the  muscles  the 
knife  should  be  directed  rather  obliquely,  in  order  that  the  edge  of 
the  musculo-tegumentary  flap  may  be  beveled  at  the  expense  of  the 
deeper  structures  so  that  the  muscles  will  not  protrude  beyond  the 
edges  of  the  skin,  which  retracts  considerably  when  it  is  cut.  Care 
should  be  taken  that  this  flap  is  not  tongue-shaped. 

This  outer  deltoid  flap  is  seized  with  the  fingers  and  dissected 
away  from  the  surface  of  the  bone  and  reflected  up  over  the  shoulder. 
The  spurting  branches  of  the  circumflex  artery  are  seized  with  forceps 
and  tied.  The  capsule  of  the  joint  being  now  exposed,  the  joint  may 
be  opened  by  cutting  through  the  capsule,  from  before  backward,  with 
the  edge  of  the  knife  applied  directly  against  the  upper  surface  of  the 
head  of  the  bone,  the  long  tendon  of  the  biceps  being  cut  at  the  same 
time.  The  arm  is  rotated  outward,  and  the  attachment  of  the  sub- 
scapularis  cut  from  the  lesser  trochanter;  then  rotating  inward,  the 
tendons  which  are  attached  to  the  upper  and  posterior  border  of  the 
greater  trochanter  are  divided,  when  the  head  of  the  bone  drops  away 
from  the  glenoid  cavity. 

The  joint  being  thus  widely  open,  the  upper  end  of  the  humerus 
is  dragged  outward  away  from  the  glenoid  cavity,  and  with  a  long 
knife  the  soft  parts,  attached  to  its  inner  aspect,  are  cut  away  from 
the  bone,  the  edge  of  the  knife  being  held  close  against  the  surface 
of  the  bone,  in  order  to  avoid  injuring  the  brachial  vessels,  which  run 
parallel  with  and  close  to  the  inner  surface  of  the  humerus.  After 
the  soft  parts  have  been  thus  separated  from  the  inner  aspect  of  the 
humerus  to  a  point  about  one  inch  below  the  anterior  fold  of  the  axilla, 
the  edge  of  the  knife  is  turned  inward,  and  with  a  final  stroke  a  short 
inner  flap  is  cut,  dividing  the  vessels  at  the  same  time.  Just  before 
this  final  cut,  which  divides  the  vessels,  is  made,  an  assistant  grasps 
the  mass  of  soft  parts,  which  includes  the  brachial  vessels,  and  com- 
presses them  until  the  operator  can  secure  the  ends  of  the  severed 
artery  and  accompanying  veins;  these  are  then  ligated  and  the  nerves 
drawn  down  and  cut  short. 


540 


UPPER  EXTREMITY. 


joinf;^;2!";^!*  ::sz°;nliez-  *  1ztvot  resect,on  ot  eib- 


AMPUTATIONS,  RESECTIONS,  ETC. 


541 


The  wound  is  closed  with  interrupted  catgut  sutures,  a  drainage 
tube  which  reaches  to  the  glenoid  cavity  being  left  protruding  through 
the  posterior  part  of  the  wound. 


Pig.  235.—  Resection  of  Wrist-joint.  Ah,  annular  ligament  split  to  show 
the  tendons  of  extensor  secundi  (EX.8)  and  extensor  carpi  radialis  brevior 
(EX.C.R.B);  EX.I.,  tendon  of  extensor  indicis. 


Resections.  Wrist-joint. — A  tourniquet  is  applied  above  the 
elbow,  in  order  that  the  operation  may  be  bloodless.  A  dorsal  incision 
is  made,  commencing  below,  at  the  middle  of  the  ulnar  border  of  the 
metacarpal  bone  of  the  index  finger,  and  this  is  continued  upward, 


542  UPPER  EXTREMITY. 

over  the  middle  of  the  posterior  surface  of  the  radius,  to  a  point  one 
inch  above  the  level  of  the  wrist-joint.  This  incision  passes  through 
the  skin  and  fat  and  runs  parallel  with  the  outer  border  of  the  extensor 
tendon  of  the  index  finger,  the  extensor  indicis. 

This  incision  is  then  gradually  deepened  step  by  step,  and  in  its 
lower  part  one  should  avoid  opening  the  sheath  of  the  extensor  in- 
dicis; in  the  upper  part  of  the  incision,  nearer  to  the  wrist-joint,  the 
tendon  of  the  extensor  carpi  radialis  brevior,  which  is  attached  to  the 
base  of  the  third  metacarpal  (that  of  middle  finger),  and  the  tendon 
of  the  extensor  secundi  are  exposed.  We  keep  to  the  inner,  ulnar, 
side  of  these  tendons,  drawing  them  toward  the  outer,  radial,  side  of 
the  wound  with  a  blunt  hook,  and  thus  avoid  cutting  them.  The 
wrist-joint  is  then  entered  by  cutting  through  its  posterior  ligament, 
between  the  tendons  of  the  extensor  indicis  and  the  extensor  secundi. 
With  blunt  retractors  the  tendons  of  the  extensor  indicis  and  ex- 
tensor communis  are  drawn  toward  the  ulnar  border  of  the  hand, 
and  the  tendons  of  the  extensor  secundi  and  extensor  carpi  radialis 
brevior  toward  the  radial  border.  Above  the  joint  the  incision  pene- 
trates to  the  surface  of  the  radius  between  the  bunch  of  tendons 
(extensor  communis  digitorum  and  extensor  indicis),  to  the  ulnar 
side,  and  the  extensor  secundi,  to  the  radial  side.  The  edges  of  the 
wound,  including  the  tendons,  being  well  retracted,  an  elevator  is 
introduced  and  all  the  soft  parts  separated  from  the  bones,  working 
as  close  as  possible  to  the  surface  of  the  bone.  It  may  be  necessary 
to  partially  separate  the  attachment  of  the  tendon  of  the  extensor 
carpi  radialis  brevior  from  the  base  of  the  third  metacarpal.  This 
is  accomplished  with  the  elevator  or  by  chipping  away  a  thin  sliver 
of  the  bone  with  a  chisel;  the  tendon  should  not  be  divided  with 
the  knife. 

After  the  carpal  bones  have  been  freely  exposed  the  wrist  is  flexed 
and  the  first  row  is  removed,  commencing  with  the  scaphoid,  then  the 
semilunar, — which  adjoins  it, — and  finally  the  cuneiform.  The  pisi- 
form, which  articulates  with  the  anterior  surface  of  the  cuneiform 
and  to  which  the  tendon  of  the  flexor  carpi  ulnaris  is  attached,  is 
allowed  to  remain  unless  it  is  diseased. 

With  the  wrist  still  flexed,  thus  giving  better  access  to  the  carpus, 
the  second  row  of  carpal  bones  is  now  excised,  commencing  with  the 
os  magnum,  which  is  easily  recognized  by  its  prominent  rounded  head. 
This  bone  is  seized  with  a  small  lion-tooth  forceps,  isolated,  and  re- 
moved.   Then  the  trapezoid  tying  to  the  outer  side  of  the  os  magnum 


AMPUTATIONS,  RESECTIONS,  ETC.  543 

and  articulating  with  the  metacarpal  bone  of  the  index  finger;  after 
this,  the  unciform  is  seized  with  the  forceps  and  removed;  the  trape- 
zium, which  articulates  with  the  metacarpal  bone  of  the  thumb,  is 
allowed  to  remain,  if  its  condition  permits,  as  its  removal  interferes 
much  with  the  function  of  the  thumb. 

It  is  not  always  necessary  to  remove  all  the  bones  of  the  carpus; 
when  diseased,  they  may  often  be  readily  enucleated  with  a  sharp 
spoon;  at  other  times  the  ligamentous  bands  which  join  the  bones  to 
each  other  and  to  the  bases  of  the  metacarpal  bones  must  be  cut  before 
they  can  be  enucleated,  and  in  doing  this  one  should  be  careful  that 
the  point  of  the  knife  does  not  wound  the  structures  in  the  palm  of 
the  hand.  There  may  be  some  difficulty  in  removing  the  scaphoid. 
In  excising  this  bone,  and  also  the  trapezium,  one  should  remember 
that  the  radial  artery  lies  in  close  proximity  to  their  posterior  surfaces. 
Although  this  vessel  is  usually  separated  from  the  bones  when  the  soft 
parts  are  detached  with  the  elevator,  and  is  therefore  not  endan- 
gered, yet  one  should  look  out  for  the  point  of  his  knife. 

The  removal  of  the  unciform  is  rather  difficult,  owing  to  the 
irregularity  of  its  hook-like  process  and  its  muscular  attachments.  It 
may  be  seized  with  a  toothed  bone  forceps,  and,  by  twisting  it  and  at 
the  same  time  cutting  with  the  edge  of  the  knife  close  to  the  bone,  it 
may  be  removed. 

If  the  ends  of  the  radius  and  ulna  are  to.  be  removed,  the  soft 
parts,  including  the  tendons,  are  separated  from  the  posterior  surface 
of  the  bones  with  the  periosteum  elevator;  the  lateral  ligaments  are 
also  detached  from  the  bones,  preferably  with  the  periosteum  elevator 
rather  than  with  the  knife,  taking  care  to  avoid  the  radial  artery  as 
it  winds  around  the  outer  side  of  the  wrist.  The  lower  ends  of  the 
bones  are  then  forced  well  out  of  the  wound  and  the  soft  parts  sepa- 
rated from  their  anterior  surfaces,  working  close  to  the  bone  or  sub- 
periosteal^, and  finally  the  ends  of  the  bones  are  sawn  off.  One 
should  avoid  the  ulnar  artery  and  nerve,  anteriorly,  toward  the  ulnar 
side.    The  tourniquet  may  now  be  removed. 

There  are  usually  no  vessels  to  tie,  none  of  importance  being 
cut.  The  hand  is  placed  upon  a  straight  anterior  splint  and  the  wound 
partly  closed  by  interrupted  sutures  and  packed  with  iodoform  gauze. 

Elbow-joint  (Langenbeck). — A  tourniquet  is  placed  about  the 
upper  part  of  the  arm.    The  operation  should  be  done  subperiosteally. 

The  arm,  with  the  elbow  flexed,  is  thrown  across  the  patient's 
chest  and  steadied  by  an  assistant;    the  operator  usually  stands  on 


544  UPPER  EXTREMITY. 

same  side  as  the  diseased  joint,  although  at  times  it  is  convenient  to 
change  to  the  other  side.  An  incision,  about  four  inches  long,  is 
made  upon  the  posterior  aspect  of  the  joint.  This  incision  commences 
about  two  inches  above  the  upper  border  of  the  olecranon  process  and 
is  continued  downward  upon  the  posterior  triangular  surface  of  the 
olecranon  and  ulna,  passing,  not  through  the  middle  of  this  surface, 
but  a  little  to  the  inner  side  of  the  middle  line  and  ending  on  its 
inner  border  (see  Fig.  234).  This  incision  should  be  made  with  a 
heavy  resection  knife,  and  throughout  its  whole  length  should  pene- 
trate through  all  the  soft  parts,  including  the  periosteum,  down  to 
the  bone.  The  upper  part  of  this  incision  splits  the  tendon  of  the 
triceps  lengthwise  right  down  to  its  attachment  to  the  upper  border 
of  the  olecranon,  and  passes  through  the  posterior  ligament  of  the 
joint  to  the  surface  of  the  humerus.  The  lower  part  of  the  incision, 
corresponding  to  the  posterior  surface  of  the  olecranon,  passes  through 
the  periosteum  to  the  bone. 

Sharp  retractors  are  introduced  into  the  upper  part  of  the  wound, 
and  the  attachment  of  the  triceps  tendon  is  chiseled  away  from  the 
upper  border,  surface,  of  the  olecranon  process  on  either  side,  taking 
a  very  thin  shell  of  bone  with  it;  this  separation  may  also  be  accom- 
plished with  the  knife,  cutting  close  to  the  bone,  but  the  subcortical 
separation  with  the  chisel  is  preferable. 

The  periosteum  elevator  is  now  used  to  separate  the  soft  parts, 
including  the  periosteum,  from  the  posterior  surface  and  sides  of 
the  olecranon  process  and  the  adjoining  upper  part  of  the  ulna  and 
lower  end  of  the  humerus,  working  first  inward  toward  the  inner 
condyle  and  keeping  close  to  the  bone,  as  this  mass  of  soft  parts 
includes  the  ulnar  nerve,  which  is  lodged  in  the  groove  between  the 
inner  condyle  and  the  olecranon;  if  we  work  subperiosteally,  or  very 
close  to  the  surface  of  the  bone,  the  ulnar  nerve  is  not  seen  and  not 
endangered.  To  retract  this  mass  of  soft  parts  as  it  is  detached  from 
the  bone,  one  should  use  a  blunt-pronged  retractor.  The  separation 
of  the  soft  parts  is  continued  inward  and  around  the  inner  epicon- 
dyle.  In  separating  the  soft  parts  from  the  inner  epicondyle  one 
should  use  the  chisel  rather  than  the  knife,  since  the  tendon  com- 
mon to  the  superficial  flexor  muscles  is  attached  here,  and  it  would 
be  disadvantageous  to  cut  it.  In  a  similar  manner  the  soft  parts, 
including  the  periosteum,  are  detached  from  the  outer  side  of  the 
olecranon,  continuing  outward  until  the  external  epicondyle  is  de- 
nuded.   To  the  external  epicondyle  is  attached  the  tendon  common 


AMPUTATIONS,  RESECTIONS,  ETC.  545 

to  the  superficial  extensors,  and  therefore  one  should  avoid  using 
the  knife  here. 

The  separation  of  the  soft  parts  can  be  accomplished  almost 
entirely  with  the  elevator,  if  necessary  using  considerable  force  with 
the  sharp  edge  of  the  elevator  applied  directly  upon  the  bare  surface 
of  the  bone;  but  it  may  be  necessary  here  and  there  to  help  one's 
self  with  the  chisel  and  occasional  snips  with  the  knife.  Upon  the 
posterior  surface  of  the  olecranon  the  knife  may  be  used  a  little 
more  freely,  as  here  the  periosteum  is  thick  and  fibrous,  being  rein- 
forced by  the  triceps  tendon,  and  is  almost  impossible  to  separate 
with  the  elevator. 

After  having  denuded  the  whole  of  the  olecranon  process  and 
the  contiguous  portions  of  the  humerus,  ulna,  and  radius  out  beyond 
the  epicondyles,  the  elbow  is  flexed  and  the  lower  end  of  the  humerus 
forced  out  of  the  wound,  cutting  away  any  remaining  restricting 
bands.  The  soft  parts  about  the  anterior  aspect  of  the  lower  end 
of  the  humerus  are  then  quickly  separated  with  the  elevator  and  the 
articular  end  of  the  bone  sawn  off.  The  section  should  be  made 
through  a  plane  parallel  with  the  articular  surface.  Then,  in  a  like 
manner,  the  upper  end  of  the  radius  and  ulna  are  stripped  of  soft 
parts  and  sawn  off.  The  diseased  synovial  membrane  may  now  be 
completely  excised  with  toothed  forceps  and  blunt-pointed,  curved 
scissors.  One  should  avoid  injuring  the  structures  in  front  of  the 
joint,  brachial  artery,  etc.,  with  the  point  of  the  knife.  After  the 
resection  has  been  completed  the  tourniquet  may  be  removed.  As  a 
rule,  there  are  no  vessels  to  tie.  The  incision  is  closed,  except  for 
a  part  of  its  length,  which  is  left  open  for  drainage,  and  the  arm  put 
up  in  a  position  of  almost  complete  extension  in  a  splint  or  plaster 
of  Paris  with  a  big  wad  of  dressings. 

After  two  weeks  the  arm  may  be  gradually  or  at  once  flexed  to 
nearly  a  right  angle,  which  is  the  best  position  for  ankylosis.  Occa- 
sionally we  get  some  motion. 

Shoulder-joint  (Subperiosteal  Method  of  Ollier  and 
Hueter). — The  arm  lies  at  the  side,  slightly  abducted  and  rotated 
outward,  so  that  the  greater  tuberosity  looks  outward.  An  incision  is 
made  which  commences  above,  to  the  outer  side  of  the  coracoid 
process,  and  passes  downward,  upon  the  front  of  the  arm,  for  a  dis- 
tance of  five  inches;  this  incision,  throughout  its  whole  length,  is 
carried  deep  to  the  bone  (see  Fig.  231).  When  the  edges  of  the  wound 
are  held  apart  with  blunt-pronged  retractors,  the  long  tendon  of  the 


546  UPPER  EXTREMITY. 

biceps,  as  it  lies  in  the  bicipital  groove  between  the  two  tuberosities, 
is  exposed.  This  tendon  emerges  from  within  the  joint  beneath  the 
lower  border  of  the  capsule. 

This  incision  above,  to  the  outer  side  of  the  coracoid  process, 
should  extend  as  high  as  the  clavicle,  in  order  to  allow  easy  access 
to  the  capsule  and  to  the  head  of  the  humerus. 

A  director  is  now  introduced  alongside  of  the  long  biceps  tendon, 
beneath  the  lower  border  of  the  capsule,  and  well  up  into  the  joint, 
and  upon  this  the  capsule  is  divided  as  far  upward  as  the  upper 
border  of  the  glenoid  cavity;  in  this  way  the  capsule  is  split  longi- 
tudinally throughout  its  entire  length  (the  coraco-humeral  ligament, 
which  is  a  part  of  the  capsule,  is  also  divided  in  this  cut),  and  the 
joint  is  thus  freely  opened  upon  its  anterior  aspect. 

The  tendon  of  the  biceps  is  now  lifted  out  of  its  groove  and 
drawn  outward  with  a  blunt  hook,  and  the  periosteum  incised  in  the 
upper  part  of  the  floor  of  the  bicipital  groove,  between  the  two 
tuberosities;  an  elevator,  with  a  sharp  edge,  is  then  introduced  into 
the  incision  in  the  periosteum,  and  this,  together  with  the  attach- 
ment of  the  capsule,  is  separated  from  the  inner  side  of  the  neck  of 
the  bone.  The  tendon  of  the  subscapularis  is  very  intimately  at- 
tached to  the  lesser  tuberosity,  and  in  order  to  separate  this  it  may 
be  necessary  to  use  the  knife  to  some  extent,  cutting  close  upon  the 
surface  of  the  bone,  or,  what  is  preferable,  one  may,  with  the  chisel, 
chip  off  a  thin  layer  of  the  cortex,  carrying  the  attached  tendon  with 
it. 

In  separating  the  capsule  from  its  attachment  around  the  neck 
of  the  bone  it  will  be  necessary,  here  and  there,  to  use  the  knife, 
cutting  with  its  edge  applied  close  to  the  surface  of  the  bone. 

After  the  parts  on  the  inner  aspect  of  the  bone  have  been  thus 
separated,  and  while  the  arm  is  rotated  inward  and  the  long  tendon 
of  the  biceps  hooked  over  toward  the  inner  side,  the  periosteum, 
together  with  the  attachment  of  the  capsule,  is  separated  from  the 
outer  side  of  the  bone;  this  is  accomplished  chiefly  with  the  peri- 
osteum elevator,  with  occasional  snips  with  the  knife.  The  tendons 
attached  to  the  upper  and  posterior  borders  of  the  greater  tuberosity 
are  intimately  united  with  the  bone,  and,  if  they  cannot  be  separated 
with  the  periosteum  elevator,  one  may  use  the  chisel,  as  on  the  inner 
side,  removing  a  thin  shell  of  the  cortex  along  with  the  tendon 
attachments.  During  this  part  of  the  operation  the  arm  is  rotated 
more  and  more  inward. 


AMPUTATIONS,  RESECTIONS,  ETC.  547 

After  the  upper  end  of  the  bone  has  been  thoroughly  isolated 
we  find  it  lying  in  a  sac,  formed  above  by  the  detached  capsule,  which 
is  continuous  below  with  the  periosteum  and  tendons  that  have  been 
separated  from  the  bone. 

The  head  of  the  bone  is  now  thrown  out  of  this  sac  and  out  of 
the  incision,  and  may  be  sawn  off  with  the  flat  saw,  protecting  the 
neighboring  soft  parts,  or  the  chain  or  Gigli  saw  may  be  used,  or  it 
may  be  knocked  off  with  a  broad  chisel. 

After  the  head  of  the  bone  has  been  removed,  the  interior  of 
the  joint  becomes  accessible,  and  one  may  dissect  away  all  the  syn- 
ovial membrane  lining  the  joint  with  toothed  forceps  and  strong, 
blunt-pointed  scissors,  curved  on  the  flat. 

The  glenoid  surface  of  the  scapula,  if  diseased,  may  be  thor- 
oughly curetted  with  the  sharp  spoon,  or  chiseled  or  gouged  out  with 
the  rongeur  bone  forceps.  Usually  no  vessels  of  importance  are  cut; 
any  spurting  points  may  be  caught  and  tied  as  the  operation  pro- 
gresses. 

The  cavity  of  the  joint  should  be  freely  drained  through  the 
lower  part  of  the  incision,  using  a  good-sized  tube.  An  additional 
opening  may  be  made  posteriorly  to  provide  still  better  drainage. 
This  opening  is  made  by  pushing  an  artery  forceps  through  the  mass 
of  deltoid  muscle  from  within  and  then  incising  the  skin  with  the 
knife  upon  this.  We  avoid  making  the  opening  through  the  deltoid 
with  the  knife  in  order  not  to  wound  the  circumflex  nerve  and  ves- 
sels. The  opening  through  the  muscle  may  be  made  as  large  as 
desired  by  spreading  the  blades  of  the  forceps.  In  closing  the  incis- 
ion interrupted  silk-worm  gut  sutures,  which  pass  through  all  the 
structures,  including  the  edges  of  the  split  capsule,  should  be  em- 
ployed. 

If  it  is  intended  to  remove  the  head  of  the  bone  only,  it  is  not 
necessary  to  separate  the  periosteum  for  more  than  a  short  distance 
upon  the  shaft.  Usually  separation  of  the  capsule  around  the  an- 
atomical neck  and  the  tendons  partially  from  the  greater  and  lesser 
tuberosities  will  give  sufficient  room  to  permit  of  the  excision  of  the 
head  of  the  bone.  Only  when  the  head  of  the  bone  is  to  be  excised 
below  the  trochanters  is  it  necessary  to  separate  the  periosteum  and 
tendons  for  a  greater  distance  below  the  anatomical  neck. 

The  operation  as  described  above  differs  from  Langenbeck's  only 
as  regards  the  incision.  The  incision  of  Langenbeck  commences 
above  at  the  acromion  process,  and  is  therefore  more  external;  pass- 


543  UPPER  EXTREMITY. 

ing  through  the  body  of  the  deltoid,  it  divides  the  circumflex  nerve, 
and  is  therefore  likely  to  be  followed  by  impairment  of  the  function 
of  the  deltoid. 

Tendon  Suture. — Tendons  may  be  found  divided  as  a  complication 
of  a  wound,  or  they  may  be  accidentally  cut  by  the  surgeon  during  the 
course  of  an  operation  about  a  joint;  one  or  several  may  be  severed. 
The  proximal  portion  of  the  tendon,  that  which  is  joined  to  the  muscle, 
may  be  separated  a  considerable  distance  from  the  distal  portion,  owing 
to  the  contraction  of  the  muscle,  and  at  times  considerable  search  may 
be  necessary  to  secure  it,  or  it  may  be  necessary  to  lay  the  sheath  of  the 
tendon  open  for  this  purpose. 

The  ends  should  be  approximated  and  joined  by  a  catgut  suture, 


Fig.  236.— Divided  Tendon  Reunited  by  a  Single  Mattress  Suture. 

one  passing  through  the  tendon  proper  being  probably  the  most  satis- 
factory. If  the  flexor  tendons  are  divided,  in  order  to  coapt  the  ends 
and  retain  them  in  position  with  the  minimum  degree  of  tension,  the 
joint  must  be  placed  in  a  position  of  flexion,  and  the  reverse  when  the 
extensor  tendons  are  severed.  Asepsis  is  a  necessary  condition  to 
healing;  if  the  parts  are  infected,  an  effort  should  be  made  to  render 
them  sterile,  and  under  these  circumstances  drainage  in  addition  is 
probably  advisable. 

Nerve  Suture. — A  nerve-trunk  may  be  severed,  either  accidentally 
by  the  surgeon  during  the  course  of  an  operation  or  the  condition  may 
be  encountered  as  a  complication  of  an  accidental  wound. 

The  ends  should  be  approximated  and  united  with  one  or  more 


AMPUTATIONS,  RESECTION'S,  ETC. 


549 


plain  catgut  sutures,  which  may  be  passed  through  the  body  of  the 
nerve  proper.  The  union  may  be  effected  immediately  after  the  oc- 
currence of  the  accident  or  after  the  lapse  of  considerable  time.  If 
immediate,  it  is  simply  necessary  to  coapt  the  ends  and  retain  them 
in  position  with  one  or  two  sutures;  if  after  the  lapse  of  a  considerable 
period,  it  will  be  necessary  to  search  for  the  ends  of  the  divided  nerve, 
and,  after  they  are  found,  freshen  them,  before  uniting  them,  end  to 
end,  by  suture.    Plain  catgut  is  preferable  for  the  suture  material. 

Intravenous  Saline  Infusion.  —  Any  prominent  superficial  vein 
may  be  used  for  this  purpose;  the  median  cephalic  at  the  bend  of  the 
elbow  is  the  one  usually  selected.  A  tourniquet  is  first  applied  about 
the  arm,  high  up  near  the  axilla  and  just  sufficiently  tight  to  constrict 
the  superficial  veins,  but  not  tight  enough  to  shut  off  the  arterial  cur- 
rent; this  causes  the  superficial  veins  to  become  swollen  and  more  con- 


Fig.  237.— Superficial  Vein  Exposed  for  Saline  Infusion.  The  vein,  -which 
is  raised  upon  the  director,  has  been  opened  ready  to  introduce  the  cannula. 
Suture  (A)  has  been  tied.  Suture  (B)  surrounds  the  vein,  but  has  not  been 
tied;  one  loop  of  the  knot  has  been  taken,  but  not  drawn  tight. 


ispicuous.  The  skin  is  then  pinched  up  over  the  vein  and  may  be  in- 
cised by  transfixion  with  the  knife  or  with  the  scissors,  care  being  taken 
not  to  injure  the  vein  itself.  The  vein  is  then  thoroughly  isolated  for 
about  one  inch  and  raised  well  out  of  its  bed  upon  a  director,  after 
which  a  double  catgut  ligature  is  passed  around  the  vein.  This  liga- 
ture is  then  cut,  so  as  to  leave  the  vein  surrounded  by  two  ligatures, 
one  above  and  the  other  below.  A  single  loop  of  a  knot  is  taken  loosely 
in  the  upper  ligature,  the  ends  of  which  are  left  long.  The  vein  is  now 
freely  opened  with  a  narrow-bladed  knife  and  the  lower  ligature  then 
tied  tight  around  the  vein.  Through  the  opening  made  in  the  vein  the 
end  of  the  cannula  is  slipped  up  into  the  vein  beyond  the  upper  liga- 
ture, which  is  then  tied  fast  about  the  cannula,  in  order  to  retain  it 
securely  in  place  within  the  vein. 

Care  should  be  taken  to  introduce  the  cannula  into  the  lumen 
of  the  vein,  and  not  into  the  loose  connective  tissue  that  surrounds 


550  UPPER  EXTREMITY. 

the  vein.  This  is  an  accident  which  may  readily  occur,  and  is  to  be 
avoided  by  thoroughly  isolating  the  vein  and  lifting  it  well  out  of  its 
bed  before  incising  it.  Before  the  cannula  is  introduced  into  the  vein 
the  solution  should  be  allowed  to  flow  in  order  to  fill  the  cannula  and 
thus  avoid  carrying  air  into  the  vein;  although  it  is  of  no  consequence 
if  a  small  quantity  of  air  does  enter  the  vein,  nevertheless  this  should 
be  avoided  if  possible. 

After  the  ligature  has  been  tied  and  the  cannula  thus  secured  in 
the  vein,  the  tourniquet  is  removed  from  the  arm  and  the  fluid  allowed 
to  flow;  from  1  to  2  quarts  at  a  temperature  of  about  115°  F.  may  be 
introduced.1  The  reservoir  should  be  held  at  an  elevation  of  two 
feet. 


1  A  degree  of  heat  that  the  hand  can  conveniently  endure  if  no  thermometer  is 
at  hand. 


PART  X. 

THE  LOWER  EXTREMITY. 


THE  THIGH. 

The  muscles  and  other  structures  of  the  thigh  are  enveloped  by 
the  skin  and  the  superficial  fascia,  which  is  areolar  in  structure  and  in- 
cludes the  subcutaneous  fat.  These  layers  are  loose,  and  movable  upon 
the  deeper  parts.  Beneath  the  fat  (superficial  fascia)  there  is  a 
strong,  tense,  fibrous  envelope,  thicker  in  some  parts  than  in  others, 
— the  proper,  or  deep,  fascia, — which,  in  the  region  of  the  thigh,  is 
called  the  fascia  lata.  This  layer  is  attached  above  to  Poupart's 
ligament,  the  crest  of  the  pubis,  sacrum,  and  rami  of  the  pubis,  and 
below — about  the  knee-joint,  to  all  the  prominent  bony  points;  it 
confines  the  muscles  and  furnishes  septa,  which  pass  in  between  the 
different  groups  of  muscles  to  be  attached  to  the  ridges  on  the  femur. 
Beneath  the  skin,  in  the  fatty  layer,  ramify  the  various  subcutaneous 
veins  and  nerves,  and  in  the  region  of  the  groin  the  subcutaneous 
arterial  branches  that  are  derived  from  the  femoral. 

The  Gluteal  Region.  —  The  gluteal  region  corresponds  to  the 
upper  back  part  of  the  thigh,  and  presents  the  prominence  of  the  but- 
tock. This  is  more  developed  in  some  persons  than  in  others,  espe- 
cially in  females,  and  is  due  chiefly  to  the  cushion  of  fat  beneath  the 
skin. 

After  the  skin  and  fat  have  been  reflected,  the  deep  fascia,  fascia 
lata,  is  exposed.  This  fascia  is  rather  thin  in  this  region,  and  through 
it  the  fasciculi  of  the  gluteus  maximus  muscle  may  be  recognized. 
The  fascia  lata  is  attached  above  to  the  crest  of  the  ilium;  below  it 
is  continuous  with  the  same  layer  of  fascia  upon  the  back  of  the  thigh; 
internally  it  is  attached  to  the  sacrum  and  coccyx. 

The  gluteus  maximus  is  a  broad,  thick  muscle;  it  arises  from  the 
upper,  posterior  portion  of  the  external  surface  of  the  ilium,  from  the 
side  of  the  sacrum  and  coccyx,  from  the  lumbo-sacral  aponeurosis, 
and  from  the  great  sacro-sciatic  ligament.  In  coarse  bundles  its 
fibers  pass  downward  and  outward;  the  upper  fibers  become  tendons, 
and  pass  across  the  great  trochanter  and  are  inserted  into  the  fascia 
lata  upon  the  outer  aspect  of  the  thigh;  the  lower  fibers  are  attached 

(551) 


552  LOWER  EXTREMITY. 

to  the  femur  along  the  line  which  passes  from  the  great  trochanter 
downward  to  the  linea  aspera. 

The  muscle  should  be  cut  through  at  right  angles  to  the  course 
of  its  fibers  and  reflected,  when  the  bursa?  beneath  it,  one  corre- 
sponding to  the  trochanter  major  and  the  other  to  the  tuber  ischii, 
may  be  examined  and  the  parts  which  lie  beneath  the  muscle  exposed 
to  view.  Above  and  in  front  is  the  posterior  portion  of  the  gluteus 
medius,  and  below  this,  but  upon  the  same  plane,  the  pyriformis; 
these  two  muscles  are  separated  from  each  other  by  a  cellular  interval, 
through  which  the  gluteal  vessels  and  nerves  are  seen  to  emerge  from 
within  the  pelvis.  Below  the  pyriformis,  but  still  upon  the  same 
plane,  are  the  two  gemelli  and  the  tendon  of  the  obturator  internus. 
Still  lower  is  found  the  quadratus  femoris,  which  is  really  the  upper 
part  of  the  adductor  magnus  muscle.  These  muscles  are  all  attached 
to  the  femur  at  or  near  the  great  trochanter.  Passing  downward  from 
the  tuberosity  of  the  ischium  are  the  semimembranosus  and  the  semi- 
tendinosus  and  biceps  muscles. 

The  space  which  exists  in  the  skeleton  between  the  lateral  border 
of  the  sacrum  and  coccyx  and  the  margin  of  the  ischium  is  converted 
into  two  foramina,  the  greater  and  lesser  sacro-sciatic  foramina,  by 
the  greater  and  lesser  sacro-sciatic  ligaments.  The  greater  sacro-sciatic 
ligament  is  attached  by  its  broad  base  to  the  margin  of  the  sacrum  and 
coccyx  and  by  its  other  end  to  the  tuberosity  of  the  ischium;  the  poste- 
rior surface  of  the  great  sacro-sciatic  ligament  gives  attachment  to 
some  fibers  of  the  gluteus  maximus  muscle.  The  lesser  sacro-sciatic 
ligament  is  attached  to  the  margin  of  the  sacrum  and  coccyx  and  to 
the  spine  of  the  ischium;  the  lesser  is  situated  upon  a  plane  anterior 
to  the  greater. 

Through  the  greater  sacro-sciatic  foramen  emerge  the  pyriformis 
muscle;  the  gluteal  vessels  and  nerve  which  appear  above  the  pyri- 
formis, between  it  and  the  gluteus  medius;  the  sciatic  artery  and  great 
sciatic  nerve,  which  appear  below  the  pyriformis,  and  the  internal 
pudic  vessels  and  nerve.  The  internal  pudic  vessels  and  nerve,  after 
emerging  from  the  pelvis  through  the  great  sacro-sciatic  foramen, 
curve  around  the  lesser  sacro-sciatic  ligament,  close  to  the  ischium, 
and  pass  forward  into  the  deep  part  of  the  perineum. 

Stretching  the  Sciatic  Nerve. — The  patient  lies  upon  the  ab- 
domen with  a  sand  bag  under  the  lower  part  of  the  trunk.  An  incision 
three  inches  long  is  made  upon  the  back  of  the  thigh,  the  upper  end 
of  the  incision  corresponding  to  the  middle  of  a  line  drawn  from  the 


THIGH. 


553 


tuberosity  of  the  ischium  to  a  point  a  hand's  breadth  below  the 
great  trochanter;  this  incision  passes  through  the  skin  and  fat 
down  to  the  deep  fascia;  the  lower  edge  of  the  gluteus  maximus 
is  now  recognized,  and  at  this  point  the  deep  fascia,  fascia  lata, 
is  incised;  through  the  opening  thus  made  in  the  deep  fascia  two 
fingers  are  introduced  and  passed  under  the  edge  of  the  gluteus 


Fig.  238.— Stretching  Sciatic  Nerve.    B,  tendon  of  biceps;  GM,  lower  edge 
of  gluteus  maximus;  N,  sciatic  nerve. 


maximus,  and  the  sciatic  nerve  hooked  up  and  drawn  out  of  the 
wound.  Three  or  four  fingers  being  now  passed  under  the  nerve, 
it  may  be  stretched  to  the  desired  degree,  pulling  with  a  gradually 
increasing  force  up  to  one  hundred  pounds;  this  may  be  repeated 
once  or  twice;  in  order  to  regulate  the  force  one  may  use  a  scale 
and  hook.    No  vessels  are  met  with,  and  it  will  but  rarely  be  neces- 


554  LOWER  EXTREMITY. 

sary  to  apply  any  ligatures;  the  wound  in  the  skin  is  closed  without 
drainage. 

The  Anterior  Femoral  Region.  —  Upon  the  anterior  part  of  the 
thigh  just  below  the  inner  end  of  Poupart's  ligament  is  the  saphenous 
opening;  this  is  a  slit-like  opening  in  the  deep  fascia,  fascia  lata, 
through  which  the  internal  saphenous  vein  passes  to  join  the  femoral. 
Its  outer  margin  presents  a  prominent,  curved,  overhanging  edge, 
the  falciform  process.  The  femoral  vessels  are  situated  beneath  the 
iliac  portion  of  the  fascia  lata,  external  and  adjacent  to  this  falciform 
margin,  resting  upon  the  pectineus  and  ilio-psoas  muscles  (see 
Femoral  Region,  Hernia). 

This  falciform  process,  or  margin,  is  continuous  above  with 
Poupart's  ligament,  and  may  be  traced  farther  inward  into  Gimber- 
nat's  ligament;  below  it  curves  inward  and  upward  beneath  the 
saphenous  vein,  and  is  here  continuous  with  that  portion  of  the 
fascia  lata,  pubic  portion,  which  covers  the  surface  of  the  pectineus 
muscle,  being  continued  upward  upon  the  surface  of  this  muscle  and 
under  Poupart's  ligament  as  far  as  the  pectineal  line,  where  it  is 
attached  (see  Figs.  176  and  182).  In  the  upper  part  of  the  thigh, 
behind  the  femoral  vessels,  this  fascia  that  covers  the  pectineus  mus- 
cle is  continuous  with  that  which  covers  the  ilio-psoas  muscle,  the 
fascia  iliaca. 

The  saphenous  opening  is  partly  closed  by  a  wad  of  fascia,  which 
is  adherent  around  the  margin  of  the  opening  and  which  is  called 
the  fascia  cribrosa.  The  fascia  cribrosa  is  pierced  by  the  internal 
saphenous  vein,  which  passes  through  the  saphenous  opening  and 
joins  the  femoral  vein  on  its  inner  side. 

The  Inteknal  Saphenous  Vein  lies  beneath  the  fatty  layer  of 
the  skin;  it  commences  upon  the  dorsum  of  the  foot,  and  passes  up- 
ward in  front  of  the  internal  malleolus,  along  the  inner  side  of  the  leg, 
and  across  the  knee-joint  behind  the  internal  condyle,  immediately 
above  which  it  often  presents  a  pouch-like  dilatation;  it  is  continued 
upward  upon  the  inner,  front  aspect  of  the  thigh,  and  just  below 
Poupart's  ligament  passes  through  the  saphenous  opening  to  join 
the  femoral.  It  receives  many  branches  all  along  its  course.  That 
part  of  the  vein  and  its  tributaries  which  correspond  to  the  leg  and 
to  the  neighborhood  of  the  knee-joint  are  apt  to  become  very  tortu- 
ous, dilated,  and  pouched,  exhibiting  the  common  conditions  known  as 
"varicose  veins."  Just  before  it  enters  the  saphenous  opening  the 
vein  receives  many  branches  from  the  front  and  inner  side  of  the 


THIGH.  555 

thigh,  all  radiating  toward  the  saphenous  opening,  and  here  also  it 
receives  the  veins  which  correspond  to  the  subcutaneous  branches 
of  the  femoral  artery.  The  saphenous  vein  is  accompanied  by  a 
chain  of  lymphatics  which  terminate  in  nodes  located  about  the 
saphenous  opening,  and  these  may  become  enlarged  and  tender  when 
infectious  processes  are  present  below  in  the  integument  of  the  leg 
or  thigh. 

Those  lymphatics  which  are  situated  along  Poupart's  ligament 
in  the  groin  are  usually  enlarged  when  the  external  genitals  are  the 
seat  of  disease. 

In  this  anterior  femoral  region  also,  lying  beneath  the  skin,  are 
found  the  superficial  branches  from  the  femoral  artery.  The  super- 
ficial epigastric  passes  through  the  saphenous  opening  and  upward 
across  Poupart's  ligament  to  ramify  upon  the  lower  abdomen.  The 
superficial  external  pudic  passes  through  the  saphenous  opening  and 
inward  to  supply  the  skin,  etc.,  of  the  external  genitals.  The  super- 
ficial circumflex-iliac  passes  upward  and  outward,  piercing  the  deep 
fascia  external  to  the  saphenous  opening  and  runs  parallel  with,  and 
below  Poupart's  ligament,  supplying  the  skin  and  glands  in  this 
region. 

These  vessels  are  usually  cut  in  making  the  incision  for  hernia 
and  in  extirpating  diseased  glands  in  this  region. 

The  Femoeal  Arteet.  Scarpa's  Triangle. — Upon  removing  the 
integument  and  deep  fascia  from  the  upper  anterior  part  of  the  thigh 
we  expose  a  triangular  space,  Scarpa's  triangle.  This  triangle  corre- 
sponds to  the  upper  third  of  the  thigh;  its  base,  which  is  above,  is 
formed  by  Poupart's  ligament;  its  outer  border  by  the  sartorius 
muscle,  and  its  inner  border  by  the  adductor  longus.  The  apex  of 
the  triangle  is  below  where  these  muscles  meet.  The  floor  of  the 
triangle  is  formed,  from  within  outward,  by  the  adductor  longus,  the 
pectineus,  and  the  ilio-psoas. 

Passing  downward  through  this  space,  from  the  middle  of  its 
base — i.e.,  midway  between  the  anterior  superior  spine  of  the  ilium 
and  the  spine  of  the  pubic  bone — to  its  apex,  is  the  femoral  artery 
accompanied  by  the  femoral  vein.  The  femoral  artery  is  the  con- 
tinuation downward  into  the  thigh  of  the  external  iliac,  and  emerges 
from  the  abdomen  underneath  Poupart's  ligament  at  the  point  al- 
ready described.  Toward  the  lower  part  of  Scarpa's  triangle  the 
femoral  artery  is  overlapped  by  the  inner  edge  of  the  sartorius 
muscle. 


556  LOWER  EXTREMITY. 

After  traversing  Scarpa's  triangle  the  femoral  vessels  are  con- 
tinued downward  along  the  inner  side  of  the  thigh,  lying  beneath 
the  sartorius  muscle,  quite  close  to  the  femur  and  inclosed  within 
Hunter's  canal. 

Hunter's  Canal  is  a  musculo-fibrous  space  corresponding  to  the 
middle  third  of  the  thigh,  lying  close  to  the  inner  side  of  the  femur; 
its  outer  wall  is  formed  by  the  vastus  internus,  which  separates  the 
vessels  from  the  bone;  its  inner  wall  by  the  adductor  longus,  and 
in  the  lower  part  of  the  thigh  by  the  adductor  magnus;  the  space 
between  the  muscles  is  roofed  over  by  a  fibrous  sheet,  which  is  de- 
rived from  the  deep  fascia.  Hunter's  canal  ends  below,  above  the 
internal  condyle,  at  the  foramen  in  the  adductor  magnus  muscle, 
through  which  the  femoral  vessels  pass  into  the  popliteal  space. 

About  two  inches  below  Poupart's  ligament  the  femoral  artery 
gives  off  a  large  branch,  the  profunda  femoris.  This  vessel  arises 
from  the  outer  and  posterior  aspect  of  the  femoral  artery;  at  its 
origin  it  curves  slightly  outward  and  then  passes  behind  the  femoral 
artery  and  vein,  and  dips  into  the  floor  of  Scarpa's  triangle,  passing 
through  the  space  between  the  adductor  longus  and  the  pectineus; 
it  then  descends  in  the  thigh,  resting  upon  the  adductor  magnus 
along  the  inner  side  of  the  femur  and  giving  off  branches  which 
perforate  the  adductor  magnus  to  anastomose  with  branches  upon 
the  back  of  that  muscle. 

The  femoral  artery  gives  off  other  small  branches  in  Scarpa's 
triangle,  but  they  are  of  little  surgical  importance. 

As  the  femoral  artery  emerges  from  underneath  Poupart's  liga- 
ment it  is  accompanied  by  the  femoral  vein,  which  lies  to  its  inner 
side.  During  the  course  of  the  artery  through  Scarpa's  triangle 
the  vein  gradually  gets  to  lie  behind  the  artery,  and  in  Hunter's 
canal  it  is  located  behind  and  a  little  to  its  outer  side. 

As  the  femoral  vessels  pass  out  through  the  femoral  space,  be- 
neath Poupart's  ligament,  they  are  inclosed  in  a  connective  tissue 
sheath,  which  is  continuous  with  the  subperitoneal  connective  tissue 
of  the  abdomen  and  which  is  closely  adherent  all  around  the  margin 
of  the  femoral  space:  above  to  Poupart's  ligament,  below  to  the 
fascia  which  covers  the  ilio-psoas  and  pectineus  muscles,  and  inter- 
nally to  the  margin  of  Gimbernat's  ligament.  This  femoral  sheath 
is  divided  into  three  distinct  compartments  by  fibrous  septa;  the 
outer  compartment  contains  the  artery,  the  middle  one  the  vein; 
the  inner  compartment  contains  a  small  amount  of  connective  tissue 


Fig.  239.— Section  through   the  Middle  of  the  Right  Thigh.     A.  V.,  femoral   artery  and  vein  : 
G.,  gracilis  muscle  ;  E.,  rectus  muscle  ;    8.N.,  sciatic  nerve. 


THIGH.  557 

and  fat,  and  through  it  the  lymphatics  from  the  thigh  pass  into  the 
abdomen.  This  inner  compartment  is  continued  but  a  short  dis- 
tance downward  upon  the  inner  side  of  the  femoral  vein;  it  corre- 
sponds to  the  space  between  the  femoral  vein  and  the  outer  edge 
of  Gimbernat's  ligament,  and  forms  the  crural  canal,  into  which  the 
gut  descends  in  femoral  hernia. 

As  the  vessels  emerge  from  the  abdomen  under  Poupart's  liga- 
ment they  are  contained  within  their  sheath,  which  is,  in  turn,  par- 
tially covered  anteriorly  by  that  portion  of  the  fascia  lata  which  lies 
external  to  the  falciform  edge  of  the  saphenous  opening;  underneath 
Poupart's  ligament  the  vessels  within  their  sheath  rest  upon  the  ilio- 
psoas and  pectineus  muscles. 

The  ilio-psoas  muscle  is  covered  over  by  a  layer  of  fascia,  the 
iliac,  which  is  continuous  internally  with  the  fascia  that  covers  the 
pectineus  muscle  (the  pubic  portion  of  the  fascia  lata).  This  layer 
of  fascia,  which  covers  the  ilio-psoas  muscle,  is  simply  the  continua- 
tion downward,  under  Poupart's  ligament  into  the  thigh,  of  the  fascia 
iliaca,  which  covers  these  muscles  within  the  abdomen. 

The  Anterior  Crural  Nerve. — At  Poupart's  ligament,  lying 
to  the  outer  side  of  the  femoral  artery  and  imbedded  in  the  substance 
of  the  ilio-psoas  muscle,  is  the  anterior  crural  nerve.  This  nerve  is 
separated  from  the  femoral  artery  by  the  iliac  fascia,  which  invests 
the  ilio-psoas  muscle  and  is  not  seen  in  the  thigh  until  this  layer 
of  fascia  has  been  incised. 

Below  Poupart's  ligament  the  anterior  crural  nerve  divides  into 
cutaneous  and  muscular  branches.  The  internal  or  long  saphenous 
nerve,  the  largest  of  the  cutaneous  branches,  approaches  the  femoral 
artery  as  it  lies  in  Scarpa's  triangle,  and  accompanies  it  down  along 
the  inner  side  of  the  thigh,  through  Hunter's  canal.  At  the  lower 
end  of  the  canal,  where  the  femoral  vessels  pass  through  the  ad- 
ductor foramen  into  the  popliteal  space  and  just  above  the  internal 
condyle,  the  nerve  becomes  more  superficial,  lying  beneath  the  sar- 
torius;  below  the  knee-joint  it  becomes  subcutaneous,  and  runs  down 
the  inner  side  of  the  leg  in  company  with  the  internal  saphenous  vein, 
and  supplies  the  skin  of  the  leg. 

Ligation"  of  the  Femoral  Artery.  The  Common  Femoral. — 
The  common  femoral  is  sometimes  ligated  as  a  preliminary  to  exartic- 
ulation  of  the  thigh  at  the  hip- joint.  The  vessel  is  ligated  immediately 
below  Poupart's  ligament,  above  the  origin  of  the  profounda  femoris 
branch,  where  it  is  quite  superficial. 


558 


LOWER  EXTREMITY. 


An  incision  about  two  inche?  long  is  made,  commencing  above, 
at  the  middle  of  Poupart's  ligament ;  i.e.,  at  a  point  midway  between 
the  anterior  superior  iliac  spine  and  the  spine  of  the  pubes.     This 


Fig.  240. — Ligation  of  Femoral  Artery.     CF,  incision  for  ligation  of  common 
femoral;    F,  incision  for  ligation  of  femoral  in  Scarpa's  triangle. 


incision  passes  through  the  skin  and  fat  down  to  the  deep  fascia,  the 
fascia  lata.  The  pulsation  of  the  artery  may  be  readily  felt  with 
the  finger  in  the  wound. 


THIGH.  559 

The  deep  fascia  is  incised  and  the  artery  exposed  by  stripping 
away  its  connective  tissue  sheath.  An  aneurism  needle,  carrying  a 
catgut  ligature,  is  passed  around  the  vessel  from  within  outward, — 
i.e.,  between  the  vein  and  artery, — and  then  withdrawn,  thus  leaving 
the  artery  surrounded  by  the  ligature,  which  is  tied.  The  femoral 
vein,  which  lies  to  the  inner  side  of  the  artery,  can  be  tied  at  the 
same  time,  through  the  same  incision.  The  wound  is  closed  with 
several  interrupted  sutures.  This  procedure  makes  the  exarticula- 
tion  at  the  hip-joint  practically  a  bloodless  operation. 

The  Femoral  in  Scarpa's  Triangle. — The  femoral  artery  is 
occasionally  ligated  for  aneurism  involving  its  lower  portion  or  its 
continuation,  the  popliteal. 

For  this  purpose  the  ligature  is  usually  applied  in  the  lower 
part  of  Scarpa's  triangle,  about  five  inches  below  Poupart's  ligament, 
and  therefore  below  the  origin  of  its  profunda  femoris  branch.  The 
course  of  the  artery  is  indicated  by  a  line  drawn  from  a  point  above, 
midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
spine  of  the  pubes,  to  the  internal  condyle  below.  The  muscular 
guide  to  the  artery,  in  this  part  of  its  course,  is  the  inner  border  of 
the  sartorius  muscle,  which  slightly  overlaps  the  vessel. 

The  patient  is  placed  upon  the  back,  with  the  leg  rotated  slightly 
outward.  The  incision  is  made  about  three  inches  long,  correspond- 
ing to  the  inner  border  of  the  sartorius  muscle;  it  commences  above, 
about  four  inches  below  Poupart's  ligament.  This  incision  passes 
through  the  skin  and  subcutaneous  fat  and  through  the  sheath  of 
the  sartorius,  exposing  the  inner  edge  of  this  muscle;  the  muscle  is 
readily  recognized  by  the  oblique  course  of  its  fibers.  In  this  in- 
cision some  tributaries  of  the  long  saphenous  vein  are  cut  and  clamped. 
Having  fully  recognized  the  edge  of  the  sartorius  muscle,  this  is 
drawn  outward,  and  the  vessel  may  then  be  located  by  its  pulsation 
beneath  the  deep  fascia;  this  layer  of  deep  fascia  is  incised  along 
the  course  of  the  artery  and  the  vessel  thus  exposed.  In  this  situation 
the  vein  is  found  lying  behind  the  artery  and  still  slightly  to  its 
inner  side ;  the  long  saphenous  nerve  lies  a  short  distance  to  the  outer 
side  of  the  artery.  We  may  see  the  internal  cutaneous  nerve  passing 
obliquely  inward  across  the  sheath  of  the  artery. 

The  loose  connective  tissue,  which  forms  the  sheath  of  the 
artery  is  now  picked  up  with  a  thumb  forceps  and  nicked  with  the 
point  of  the  knife,  and  through  the  opening  thus  made  a  director  is 
introduced  between  the  artery  and  the  vein,  working  around  the 


560  LOWER  EXTREMITY. 

artery,  close  to  its  wall,  from  within  outward.  After  the  artery  has 
been  thus  isolated  a  catgut  ligature  is  carried  around  it,  also  from 
within  outward,  in  an  aneurism  needle.  Before  tying  the  ligature 
one  should  again  investigate  to  make  certain  that  the  artery  alone 
is  included,  and  then  tie  a  single  square  knot.  The  incision  is  closed 
with  several  catgut  sutures. 

The  Popliteal  Space. — The  femoral  artery  and  vein,  having  passed 
through  the  opening  in  the  lower  part  of  the  adductor  magnus  muscle, 
enter  the  popliteal  space,  and  are  known  here  as  the  popliteal  artery 
and  vein. 

The  popliteal  space  is  lozenge-shaped  and  situated  behind  the 
knee.  It  is  bounded  above  and  externally  by  the  biceps;  above  and 
internally  by  the  semimembranosus,  semitendinosus,  gracilis,  and 
sartorius,  the  tendons  of  these  muscles  being  known  as  the  outer  and 
inner  hamstrings,  respectively.  Below  and  externally  the  space  is 
bounded  by  the  outer  head  of  the  gastrocnemius,  and  below  and  in- 
ternally by  the  inner  head  of  the  same  muscle.  The  floor  of  the 
space  is  formed,  from  above  downward,  by  the  posterior  surface  of 
the  lower  end  of  the  femur,  the  posterior  ligament  of  the  knee-joint, 
and  the  popliteus  muscle. 

Passing  from  the  upper  angle,  through  the  space,  to  the  lower 
angle,  where  it  becomes  the  posterior  tibial,  is  the  internal  popliteal 
nerve.  In  the  upper  part  of  the  space,  emerging  from  beneath  the 
biceps  muscle,  is  the  external  popliteal  nerve ;  this  nerve  passes  down- 
ward and  outward  along  the  inner  edge  of  the  biceps  tendon. 

The  popliteal  artery,  with  its  accompanying  vein,  enters  the  pop- 
liteal space  above,  emerging  from  beneath  the  semimembranosus,  near 
the  upper  angle  of  the  space ;  therefore  in  the  upper  part  of  the  space 
the  artery  lies  to  the  inner  side  of  the  internal  popliteal  nerve;  about 
the  middle  of  the  space,  however,  the  artery  passes  underneath  the 
nerve ;  and  in  the  lower  part  of  the  space  it  is  found  to  the  outer  side 
of  the  nerve. 

The  popliteal  artery  lies  close  to  the  floor  of  the  popliteal  space, 
separated  from  the  posterior  ligament  of  the  knee-joint  by  a  little 
connective  tissue;  the  vein  is  placed  superficial  to  the  artery  and 
rather  to  its  outer  side;  the  internal  popliteal  nerve  lies  superficial 
to  the  vessels,  crossing  them  from  above  downward.  The  popliteal 
artery  gives  off  several  branches,  but  they  are  of  but  little  surgical 
importance. 

The  popliteal  space  is  covered  by  the  skin  and  superficial  fascia 


LEG.  561 

(fat)  and  by  the  deep  fascia,  which  is  stretched  between  the  ham- 
string tendons.  When  the  popliteal  artery  reaches  the  lower  part 
of  the  popliteal  space  it  divides  into  two  branches,  the  anterior  and 
posterior  tibial. 

It  is  seldom  or  never  necessary  to  tie  the  popliteal;  for  popliteal 
aneurism  the  ligation  of  the  femoral  is  preferred. 

THE  LEG. 

The  Anterior  Tibial  Artery. — Just  below  the  lower  border  of  the 
popliteus  muscle  the  anterior  tibial  artery  passes  forward,  through 
an  opening  in  the  interosseous  membrane  between  the  tibia  and  the 
fibula,  to  the  front  of  the  leg;  it  then  passes  downward,  lying  upon 
the  front  surface  of  the  interosseous  membrane,  accompanied  by  two 
vense  comites,  one  on  either  side.  In  the  upper  third  of  the  leg  the 
vessel  lies  between  the  tibialis  anticus  on  its  inner  side  and  the 
extensor  longus  pollicis  on  its  outer  side.  Upon  the  front  of  the 
ankle  the  artery  lies  beneath  the  anterior  annular  ligament,  having 
the  tendon  of  the  extensor  longus  pollicis  on  its  inner  side  and  the 
tendons  of  the  extensor  longus  digitorum  on  its  outer  side.  Upon 
the  front  of  the  ankle  the  tendon  of  the  tibialis  anticus  lies  to  the 
inner  side  of  the  tendon  of  the  extensor  longus  pollicis,  and  the 
perineus  tertius  lies  to  the  outer  side  of  the  tendons  of  the  ex- 
tensor longus  digitorum.  After  the  anterior  tibial  artery  emei-ges 
from  beneath  the  lower  border  of  the  anterior  annular  ligament, 
it  is  continued  downward  as  the  dorsalis  pedis,  lying  in  the  first 
interosseous  space,  and  giving  off  a  branch  which  passes  outward 
across  the  tarsus,  and,  lower  down,  one  which  passes  outward  across 
the  heads  of  the  metatarsal  bones.  This  latter  branch,  which  is 
known  as  the  metatarsal,  gives  off  three  descending  branches,  which 
pass  downward  upon  the  second,  third,  and  fourth  interosseous  mus- 
cles as  far  as  the  webs  of  the  toes,  where  they  each  divide  into  two 
lateral  branches,  which  are  distributed  to  the  contiguous  halves  of 
the  adjoining  toes.  These  interosseous  branches  are  for  the  supply 
of  the  adjoining  sides  of  the  fifth  and  fourth,  fourth  and  third,  and 
third  and  second  toes.  The  dorsalis  pedis  itself  descends  upon  the  first 
interosseous  muscle,  this  part  of  the  artery — i.e.,  between  the  first  and 
second  metatarsal  bones — being  called  the  dorsalis  hallucis ;  it  divides 
to  supply  the  contiguous  sides  of  the  first  (big  toe)  and  second  toes, 
supplying  also  the  inner  side  of  the  big  toe. 


562  LOWER  EXTREMITY. 

The  first  dorsal  interosseous  muscle  is  perforated  above  by  a 
large  branch  of  the  dorsalis  pedis,  which  passes  through  to  the  deep 
part  of  the  sole  of  the  foot,  to  anastomose  with  the  external  branch 
of  the  posterior  tibial  to  form  the  plantar  arch. 

The  Anterior  Tibial  Nerve,  which  is  derived  from  the  external 
popliteal,  reaches  the  anterior  tibial  artery  at  the  junction  of  the  upper 
and  middle  thirds  of  the  leg,  and  then  accompanies  it  throughout  the 
rest  of  its  course.  The  nerve  reaches  the  anterior  tibial  artery,  as  this 
vessel  lies  upon  the  interosseous  membrane,  by  curving  around  the 
upper  part  of  the  fibula  beneath  the  extensor  longus  digitorum.  Cor- 
responding to  the  middle  third  of  the  leg,  the  nerve  lies  upon  the 
front  of  the  artery,  but  in  the  lower  part  of  the  leg  it  lies  to  the 
outer  side  of  the  artery,  and  beneath  the  anterior  annular  ligament 
divides  into  an  internal  and  an  external  branch. 

Ligation  of  the  Anterior  Tibial  Artery. — The  patient  lies 
upon  the  back,  with  the  knee  somewhat  flexed  and  a  sand  bag  placed 
beneath  it.  The  linear  guide  to  the  artery  corresponds  to  a  line  drawn 
from  the  inner  side  of  the  head  of  the  fibula  to  a  point  below,  midway 
between  the  internal  and  external  malleoli. 

The  vessel  may  be  tied  in  the  middle  third  of  the  leg,  as  it  lies 
upon  the  anterior  surface  of  the  interosseous  membrane  between  the 
tibialis  anticus  on  its  inner  side  and  the  extensor  proprius  pollicis  on 
its  outer  side. 

An  incision,  about  two  fingers'  breadth  external  to  the  prominent 
edge  of  the  shin  bone  and  two  or  three  inches  long,  is  made  through 
the  skin  and  fat  down  to  the  deep  fascia.  The  deep  fascia  is  then  in- 
cised, and  working  down,  between  the  tibialis  anticus  on  the  inner  side 
and  the  extensor  proprius  pollicis  on  the  outer  side,  with  the  handle  of 
the  scalpel,  the  interosseous  membrane  is  reached.  The  foot  is  then 
somewhat  flexed  at  the  ankle — dorsal  flexion — to  relax  the  muscles, 
and  retractors  are  introduced  deep  into  the  wound,  and  the  artery, 
with  its  vense  comites  lying  upon  it,  is  exposed.  The  anterior  tibial 
nerve  lies  in  front  of  the  anterior  tibial  vessels  in  this  part  of  their 
course.  After  the  nerve  has  been  separated  from  the  artery  a  liga- 
ture is  carried  around  the  vessel  from  without  inward  and  tied. 

The  Posterior  Tibial  Artery. — This  vessel  passes  down  the  back 
of  the  leg,  and  below,  between  the  internal  malleolus  and  the  tuber- 
osity of  the  os  calcis,  it  divides  into  the  internal  and  external  plantar. 
The  posterior  tibial  is  larger  than  the  anterior,  and  at  its  origin  lies 
deep  beneath  the  muscles  of  the  calf, — gastrocnemius  and  soleus, — 


Fig.  241.— Section  through  the  Middle  of  the  Eight  Leg.  A.  A.  V.,  anterior  tibial 
artery  and  vein;  G.E.,  gastrocnemius  externus  ;  G.I.,  gastrocnemius  interims; 
P.B.,  peroneus  brevis ;  P.L.,  peroneus  longus ;  P.V„  peroneal  artery  and  vein; 
P.  V.N.,  posterior  tibial  artery  and  nerve. 


LEG.  563 

resting  upon  the  tibialis  posticus;  from  its  origin,  as  it  descends,  it 
gradually  approaches  the  tibial  side  of  the  leg. 

In  the  lower  third  of  the  leg  the  artery  is  more  superficial,  run- 
ning parallel  with  the  inner  border  of  the  tendo  Achillis  and  being 
covered  only  by  the  deep  fascia  and  the  integument.  The  posterior 
tibial  artery  is  accompanied  by  two  large  vense  comites,  one  on  either 
side  of  it. 

Between  the  os  calcis  and  the  inner  malleolus,  and  beneath  the 
origin  of  the  adductor  pollicis,  the  posterior  tibial  artery  divides  into 
its  terminal  branches,  the  internal  and  external  plantar.  The  in- 
ternal plantar,  the  smaller,  runs  along  the  inner  side  of  the  sole  of  the 
foot.  The  external  plantar  passes  outward,  beneath  the  flexor  brevis 
digitorum,  lying  upon  the  flexor  accessorius  as  far  as  the  base  of  the 
fifth  metatarsal  bone;  it  then  turns  and  runs  inward  to  the  interval 
between  the  bases  of  the  first  and  second  metatarsal  bones,  where  it 
anastomoses  with  the  large  perforating  branch  from  the  dorsalis  pedis, 
and  thus  forms  the  plantar  arch. 

From  the  plantar  arch  four  digital  branches  descend  in  the  corre- 
sponding interosseous  spaces  as  far  as  the  webs  of  the  toes,  where  they 
divide  for  the  supply  of  the  adjacent  sides  of  the  toes.  The  contig- 
uous sides  of  the  big  toe  and  second  toe  and  the  inner  side  of  the  big 
toe  are  supplied  by  the  continuation  of  the  perforating  branch  of  the 
dorsalis  pedis,  which  divides,  at  the  cleft  between  the  big  and  second 
toes,  into  two  branches.  One  passes  inward  to  supply  the  inner  border 
of  the  great  toe  and  the  other  bifurcates  to  supply  the  contiguous  sides 
of  the  great  and  second  toes. 

As  the  posterior  tibial  artery  descends  in  the  middle  of  the  space 
between  the  os  calcis  and  the  internal  malleolus,  the  venge  comites 
lie  one  on  each  side  of  it;  the  posterior  tibial  nerve,  already  di- 
vided into  the  internal  and  external  plantar,  lies  to  its  outer  side; 
still  more  externally,  close  to  the  os  calcis,  is  the  tendon  of  the  flexor 
longus  pollicis,  and  to  the  inner  side  of  the  artery,  lodged  in  the  groove 
upon  the  posterior  border  of  the  internal  malleolus,  are  the  ten- 
dons of  the  tibialis  posticus  and  flexor  longus  digitorum;  of  these 
two,  the  tibialis  posticus  being  the  more  internal  and  the  closer  to  the 
bone. 

Just  below  its  origin  the  posterior  tibial  artery  gives  off  a  large 
branch,  the  peroneal;  this  branch  descends  along  the  fibular  side  of 
the  back  of  the  leg,  covered  by  the  soleus  and  gastrocnemius  and 
lying  upon  and  partly  covered  by  the  flexor  longus  pollicis. 


564  LOWER  EXTREMITY. 

The  Posterior  Tibial  Nerve  accompanies  the  posterior  tibial 
artery;  it  is  the  continuation  of  the  internal  popliteal,  and  is  a  large 
nerve.  At  its  commencement  the  nerve  lies  to  the  inner  side  of  the 
artery,  hut,  a  short  distance  from  its  origin  the  artery  passing  ob- 
liquely inward  toward  the  tibial  side  of  the  leg  and  the  course  of  the 
nerve  being  straight,  the  nerve  thereby  gets  to  lie  to  the  outer  side 
of  the  artery.  The  posterior  tibial  nerve  continues  down  the  back  of 
the  leg  upon  the  outer  side  of  the  artery,  and  divides,  in  the  space 
between  the  os  calcis  and  the  internal  malleolus,  into  the  internal  and 
external  plantar. 

Ligation  of  the  Posterior  Tibial. — This  vessel  may  be  exposed 
and  tied  just  above  the  ankle-joint  and  to  the  inner  side  of  the  tendo 
Aehillis.  An  incision  is  made  about  two  inches  long  midway  between 
the  posterior  border  of  the  inner  malleolus  and  the  inner  border  of 
the  tendo  Aehillis.  This  incision  reaches  through  the  integument 
and  fat  down  to  the  deep  fascia.  The  deep  fascia  is  then  incised  and 
the  posterior  tibial  artery  exposed;  it  is  found  quite  superficial,  to- 
gether with  its  vense  comites,  one  on  either  side.  To  the  outer  side  of 
the  vessels,  nearer  the  tendo  Aehillis,  is  the  posterior  tibial  nerve. 
The  veins  are  separated  from  the  artery,  and  a  ligature  then  carried 
around  the  artery  in  an  aneurism  needle,  from  within  outward  in 
order  to  avoid  the  nerve,  and  tied. 

Tenotomy. — This  operation  is  done  with  a  narrow-bladed  knife 
through  a  very  small  incision  in  the  skin. 

Tendo  Achillis. — The  foot  is  strongly  flexed  so  as  to  put  the 
tendon  upon  the  stretch,  and  a  narrow  tenotomy  knife  entered  close 
to  the  inner  border  of  the  tendon  and  about  one  and  one-half  inches 
above  its  attachment  to  the  os  calcis;  the  knife  is  entered  upon  the 
flat  and  pushed  through  the  soft  parts  in  front  of  the  tendon  as  far 
as  its  outer  border;  the  blade  of  the  knife  is  then  turned  so  that  its 
cutting  edge  is  directed  toward  the  tendon,  and  with  several  strokes 
the  tendon  is  divided.  The  division  of  the  tendon  is  really  accom- 
plished by  strongly  flexing  the  foot  and  thus  making  the  tendon  very 
tense  upon  the  sharp  edge  of  the  knife. 

There  is  no  danger  of  wounding  the  posterior  tibial  vessels  and 
nerve  if  the  blade  of  the  knife  is  introduced  close  to  the  inner  border 
of  the  tendon  (see  "Posterior  Tibial  Artery,"  etc.). 

Tendons  of  the  Tibialis  Posticus  and  Flexor  Longus  Digi- 
torum. — These  tendons  are  divided  as  they  descend  in  the  groove 
upon  the  posterior  border  of  the  internal  malleolus. 


LEG.  565 

The  inner  edge  of  this  groove,  which  marks  the  posterior  border 
of  the  internal  malleolus,  should  be  recognized  and  the  tenotomy  knife 
introduced  upon  the  flat,  so  that  it  enters  in  front  of  the  tendons, 
between  the  tendons  and  the  floor  of  the  groove  upon  the  posterior 
border  of  the  internal  malleolus.  The  knife  is  then  turned  so  that  its 
cutting  edge  is  directed  toward  the  tendons,  and  by  forcibly  flexing 
(dorsal  flexion)  the  foot  and  everting  it,  thus  making  the  tendon  tense, 
their  division  is  accomplished  (see  "Posterior  Tibial  Artery,"  etc.). 

Multiple  Ligature  of  the  Subcutaneous  Veins  of  the  Leg. — This 
operation  is  performed  for  varicose  veins  of  the  leg  with  or  without 
ulcer,  and  with  very  satisfactory  results. 

The  operation  may,  in  many  cases,  be  done  under  local  cocain 
anaesthesia,  a  few  drops  being  injected  into  each  region  just  before 
the  incision  is  made;  after  several  such  injections  have  been  made 
one  may  often  dispense  with  further  injections. 

An  elastic  band  is  first  applied  about  the  thigh,  half  way  between 
the  knee  and  the  hip,  and  sufficiently  tight  to  obstruct  the  venous  re- 
turn, but  not  tight  enough  to  interfere  with  the  arterial  current; 
this  serves  to  make  the  subcutaneous  veins  stand  out  more  promi- 
nently. 

A  small  incision,  usually  about  one-half  inch  long,  is  made  with 
a  sharp  knife  just  alongside  the  vein  selected  for  ligation,  care  being 
taken  not  to  wound  the  vein. 

After  the  vein  has  been  exposed  it  is  separated  from  its  connective 
tissue  bed  with  a  director,  and  a  fine  catgut  ligature  carried  around 
it  in  the  eye  of  a  small  blunt-pointed  ligature  carrier.  After  the  lig- 
ature has  been  tied  the  small  wound  in  the  skin  is  closed  with  a  single 
catgut  stitch. 

The  first  ligature  should  be  applied  to  the  internal  saphena 
upon  the  inner  aspect  of  the  thigh,  several  inches  above  the  level  of 
the  knee-joint,  and  the  successive  ligatures  placed  below  this  point, 
thus  gradually  working  down  toward  the  foot,  or,  if  an  ulcer  is  present, 
toward  the  ulcer.  Each  prominent  vein  is  thus  treated,  using  from 
ten  to  twenty  separate  ligatures,  according  to  the  number  of  veins  that 
are  involved. 

If  an  ulcer  is  present,  all  the  enlarged  veins  radiating  from  the 
ulcer  should  be  ligated,  and  then  the  ulcer  may  be  scraped,  and,  after 
it  has  been  thoroughly  disinfected,  covered  with  skin  grafts.  Any 
veins  that  are  cut  during  the  operation  should  be  caught  with  clamps 
and  tied  with  catgut. 


566 


LOWER  EXTREMITY. 


AMPUTATIONS,  RESECTIONS,  ETC. 

Surgical  Anatomy  of  the  Skeleton  of  the  Foot. — A  knowledge 
of  the  composition  and  articulations  of  the  skeleton  of  the  foot  is  of 
much  practical  value  in  performing  the  various  amputations  upon 
this  part. 

The  tarsus  is  made  up  of  two  rows — or,  better,  two  groups — of 
irregular-shaped  bones.  The  first  row  consists  of  the  os  calcis  and 
astragalus,  the  os  calcis  occupying  the  outer  side  of  the  foot  and  form- 
ing the  heel,  the  astragalus  being  on  the  inner  side  of  the  foot,  par- 


Fig.  242. — Right  Foot.    C,  Chopart  articulation;  C",  incision  for  Chopart  amputa- 
tion; L,  Lisfranc  articulation;  L',  incision  for  Lisfranc  amputation. 


tially  resting  upon  the  os  calcis  and  entering  into  the  formation  of 
the  ankle-joint.  The  anterior,  articular  surfaces  of  these  bones  are 
on  about  the  same  plane,  and  form  an  uninterrupted  line  from  the 
outer  to  the  inner  side  of  the  foot.  The  anterior,  articular  surface  of 
the  astragalus  is  convex,  and  is  located  above  and  to  the  inner  side  of 
that  of  the  os  calcis,  which  is  rather  concave. 

The  second  group  consists  of  the  cuboid,  which  is  on  the  outer 
side  of  the  foot,  articulating  with  the  os  calcis;  the  scaphoid,  which 
is  on  the  inner  side  of  the  foot,  articulating  behind  with  the  astragalus; 


AMPUTATIONS,  RESECTIONS,  ETC.  557 

and  the  three  cuneiforms.  This  second  group  presents  anteriorly  an 
irregular  row  of  articular  surfaces  which  is  convex  toward  the  toes, 
its  outer  end  being  about  one  inch  nearer  the  ankle-joint  than  its 
inner  end. 

We  next  come  to  the  metatarsal  bones,  five  in  number,  which 
articulate  as  follows:  The  two  outer,  those  of  the  little  toe  and  the 
fourth,  with  the  cuboid;  the  third,  middle  one,  with  the  external 
cuneiform;  the  second  with  the  middle  cuneiform;  and  the  first, 
that  of  the  big  toe,  with  the  internal  cuneiform.  The  base  of  the 
fifth  metatarsal  bone  presents  a  prominent  tuberosity,  which  pro- 
jects outward  and  is  easily  felt  underneath  the  skin;  this  is  an  im- 
portant surgical  guide.  The  second  metatarsal  bone  is  characterized 
by  its  base  projecting  backward,  into  the  tarsus,  beyond  the  bases  of 
the  adjoining  metatarsal  bones;  so  that  the  tarso-metatarsal  artic- 
ular line  is  interrupted  at  this  point. 

We  therefore  have  an  articular  junction  between  the  os  calcis  and 
astragalus  behind  and  the  cuboid  and  scaphoid  in  front,  which  we 
might  call  the  Chopart  joint.  Through  this  we  do  the  Chopart 
amputation.  The  inner  end  of  the  scaphoid  presents  a  prominent 
tuberosity,  which  is  readily  felt  beneath  the  skin  just  below  and  in 
front  of  the  tip  of  the  inner  malleolus;  this  tubercle  is  the  guide  to 
the  inner  end  of  the  Chopart  joint,  the  outer  end  of  the  joint  being 
located  one  thumb's  breadth  behind  the  tuberosity  which  marks  the 
base  of  the  fifth  metatarsal  bone. 

The  articular  line  between  the  tarsus  behind  and  the  metatarsus 
in  front  might  be  called  the  Lisfranc  junction.  This  line  is  curved, 
with  its  convexity  forward  toward  the  toes.  The  outer  end  of  the 
junction  corresponds  to  the  base  of  the  metatarsal  bone  of  the  little 
toe,  which  presents  a  prominent  tuberosity  that  may  be  readily  felt 
and  which  is  the  guide  to  the  joint.  The  inner  end  of  the  Lisfranc 
junction  is  lower  than  the  outer,  being  about  one  inch  nearer  the  toes, 
and  may  be  located  two  fingers'  breadth  in  front  of  the  tuberosity  of 
the  scaphoid. 

The  line  of  the  Lisfranc  articulation  is  interrupted  by  the  pro- 
jection of  the  base  of  the  second  metatarsal  bone  rather  less  than  one- 
fourth  inch  farther  into  the  tarsus  than  the  third  metatarsal,  and  again 
by  the  fact  that  the  articulation  between  the  first  metatarsal  (big 
toe)  and  the  internal  cuneiform  is  about  half  an  inch  lower,  nearer 
the  toe,  than  that  between  the  second  metatarsal  and  the  middle 
cuneiform. 


568  LOWER  EXTREMITY. 

Exarticulation  of  the  Big  Toe.  Oval  Method. — The  toe  is 
seized  with  the  left  hand  and  a  dorsal  incision  made  upon  the  head 
(lower  extremity)  of  the  metatarsal  bone,  commencing  about  one-half 
inch  above  the  metatarso-phalangeal  joint;  this  incision  is  carried 
straight  down  to  a  point  about  one-half  inch  beyond  the  web  of  the 
toe  and  then  around  the  toe,  cutting  everything  to  the  bone. 

One  should  remember  that  the  head  of  the  metatarsal  bone  of  the 
big  toe  is  large  and  requires  a  considerable  flap  to  cover  it.  The  cor- 
ners of  the  flap  are  seized  first  on  one  side  and  then  on  the  other, 
and  the  flap  dissected  away  from  the  bone.  Flexing  the  toe,  the 
joint  is  opened  upon  its  dorsal  aspect,  the  lateral  ligaments  being  di- 
vided, while  the  toe  is  pulled  first  to  one  side  and  then  to  the  other, 
and  finally  the  remaining  attached  soft  parts  are  separated,  cutting 
close  to  the  bone  and  from  within  outward.  Spurting  vessels  are 
clamped  and  tied  and  the  wound  closed  with  four  or  five  interrupted 
catgut  sutures.  A  small  drain  may  be  left  in  situ  for  two  days.  Am- 
putation of  the  other  toes  is  done  in  a  manner  analogous  to  the  above. 

EXARTICULATION  OE  THE  BlG  TOE,  WITH  EEMOVAL  OF  THE  FlRST 

Metatarsal  Bone. — An  incision  is  made  which  begins  just  above  the 
tarso-metatarsal  joint,  articulation  of  the  metatarsal  with  the  internal 
cuneiform,  which  is  located  about  one  finger's  breadth  below  the 
tuberosity  of  the  scaphoid,  and  this  is  carried  down,  upon  the  dorsal 
surface  of  the  foot,  to  the  web  of  the  toe,  at  which  point  it  is  carried, 
in  the  form  of  an  oval,  around  the  toe  (see  Fig.  257).  This  incision, 
throughout  its  whole  extent,  reaches  to  the  bone.  The  edges  of  the 
incision  are  drawn  apart  with  retractors,  and  the  soft  parts  separated 
from  the  metatarsal  bone,  after  which  the  joint  above,  between  the 
metatarsal  and  internal  cuneiform  bones,  is  opened  and  the  meta- 
tarsal enucleated  out  of  its  bed  of  soft  parts,  cutting  with  the  edge 
of  the  knife  close  to  the  surface  of  the  bone. 

The  tendons  of  the  big  toe  are  cut  short  above  at  the  level  of  the 
tarso-metatarsal  joint.  It  is  unnecessary  to  use  a  tourniquet  in  this 
amputation.  Spurting  vessels  are  caught  and  tied,  and  after  the  bleed- 
ing has  been  checked  the  wound  is  closed  with  several  interrupted 
catgut  sutures.  The  incision  may  be  placed  upon  the  side  of  the  foot 
instead  of  upon  the  dorsum;  this  is  better  for  drainage,  but  the  scar 
is  not  so  well  located. 

Exarticulation  of  the  Little  Toe. — Amputation  of  the  little 
toe  and  its  metatarsal  bone  may  be  done  in  a  manner  similar  to  the 
preceding. 


AMPUTATIONS,  RESECTIONS,  ETC. 


569 


Foe  Ingeowing  Toe-nail.  Removal  of  the  Offending  Half 
of  the  Nail.  —  This  operation  is  done  under  local  cocain  anaesthe- 
sia. A  rubber  band  is  tied  tight  around  the  root  of  the  toe  for  the 
purpose  of  confining  the  cocain  to  this  part  and  in  order  to  control 
the  hemorrhage.  The  end  of  a  sharp-pointed  scissors  is  pushed  under 
the  nail  and  down  the  middle,  as  far  as  the  root,  and  with  this  the  nail 
is  split.  The  half  of  the  nail  which  is  to  be  removed  is  then  grasped 
with  an  artery  forceps  and  torn  away  from  the  matrix. 

Cotting  Operation. — Cocain  angesthesia.  A  rubber  band  is  tied 
around  the  root  of  the  toe.  The  soft  parts,  corresponding  to  the 
affected  side  of  the  toe,  are  transfixed  with  a  long,  narrow-bladed  knife 
and  excised.     The  incision  should  extend  backward  well  beyond  the 


Fig.  243  —Operations  for  Ingrowing  Toe-nail.  Solid  line  indicates  Cot- 
ting  operation.  Dotted  line  shows  line  of  incision  for  removal  of  half  of  the 
nail. 


root  of  the  nail.  In  addition,  the  corresponding  half  of  the  nail  may  be 
removed  as  described  above.  The  bleeding  digital  branch  upon  the 
outer  side  of  the  toe  may  be  clamped  and  tied.  Although  a  snug  band- 
age and  elevation  of  the  limb  usually  suffice  to  control  the  hemorrhage, 
still  it  is  wise  to  ligate  the  bleeding  point.  The  raw  surfaces  are  dis- 
infected and  covered  with  a  wad  of  gauze  and  a  bandage  applied. 

Amputation  theough  the  Taeso-metataesal  Aeticulation 
(Lisfeanc). — A  tourniquet  is  applied  just  above  the  knee.  The  right 
foot,  for  example.  The  foot  should  extend  over  the  end  of  the  table. 
The  guides  to  the  Lisfranc  joint  are,  on  the  outer  side  of  the  foot,  the 
prominent  base  of  the  fifth  metatarsal  bone  (little  toe)  and,  on  the 
inner  side,  the  base  of  the  first  metatarsal  (big  toe)  which  is  located 


570  LOWER  EXTREMITY. 

a  finger's  breadth  in  front  of  the  tuberosity  of  the  scaphoid.  The 
lower  part  of  the  foot  is  grasped  in  the  left  hand  (the  palm  of  the 
hand  applied  to  the  sole  of  the  foot),  with  the  thumb  upon  the  outer 
guide  and  the  index  finger  upon  the  inner  guide,  and  a  curved 
incision,  with  its  convexity  downward  toward  the  toes,  is  then  made; 
this  incision  extends  across  the  dorsum  of  the  foot,  from  its  outer 
to  its  inner  border,  commencing  and  ending  a  little  below  the  level 
of  the  joint,  so  that  when  the  skin  retracts  it  will  not  leave  the  ends 
of  the  bones  protruding  beyond  the  edge  of  the  flap  (see  Fig.  242). 
An  incision  is  then  carried  down,  along  the  outer  and  inner  borders  of 
the  foot,  from  either  end  of  the  dorsal  incision,  as  far  as  the  web  of  the 
toes. 

The  short  flap  which  has  been  marked  out  upon  the  dorsum  of 
the  foot  is  dissected  back  to  the  level  of  the  articulation  and  should 
include  only  the  integument  and  the  subcutaneous  fat. 

Now,  forcibly  flexing  the  foot,  the  extensor  tendons  on  the  dor- 
sum are  divided  to  the  bone  and  the  point  of  the  knife  inserted  into 
the  joint  behind  the  base  of  the  metatarsal  bone  of  the  little  toe,  and 
this  joint  thus  opened.  The  knife  is  then  carried  inward  across  the 
foot,  remembering  that  the  line  of  the  joint  is  not  straight,  but  con- 
vex, the  convexity  being  directed  forward  toward  the  toes. 

When  we  reach  the  point  where  the  base  of  the  metatarsal  bone 
of  the  second  toe  projects  into  the  tarsus,  the  edge  of  the  knife  is 
turned  backward  toward  the  ankle  for  about  one-fourth  inch,  and 
then,  again  turning  it  inward,  the  joint  between  the  base  of  the 
second  metatarsal  and  the  middle  cuneiform  is  opened.  The  edge  of 
the  knife  is  then  turned  forward  toward  the  toes,  and  carried  in  this 
direction  for  about  one-half  inch,  in  order  to  reach  the  level  of  the 
joint  between  the  first  metatarsal  (big  toe)  and  the  internal  cunei- 
form, which  is  then  also  opened. 

Flexing  the  foot  still  more  forcibly,  thus  causing  the  joint  to 
gape  widely,  the  metatarsus,  the  portion  of  the  foot  which  is  to  be 
amputated,  is  freed  with  the  point  of  the  scalpel  upon  its  deep  plantar 
aspect,  and  then,  with  the  long  knife,  and  cutting  close  to  the  bone, 
all  the  soft  parts  are  separated  upon  the  plantar  aspect  of  the  foot 
down  to  the  webs  of  the  toes,  at  which  point  the  long  plantar  flap  is 
cut  from  within  outward  and  the  amputation  is  complete. 

It  will  be  necessary  to  clamp  and  tie  the  dorsalis  pedis  upon  the 
dorsal  surface  of  the  foot,  near  the  inner  border,  and  in  the  large 
plantar  flap  the  branches  of  the  plantar  arch. 


AMPUTATIONS,  RESECTIONS,  ETC. 


571 


We  have  upon  the  dorsum  a  short,  semilunar  flap  which  is  com- 
posed of  skin  and  fat  only,  and  upon  the  plantar  aspect  a  long  flap 


Fig.  244.— Right  Foot,  Inner  Side.    0,  incision  for  Chopart;  L,  incision 
for  Lisfrane;  P,  incision  for  Pirogoff. 


Fig.  245.— Right  Foot,  Outer  Side.    C,  incision  for  Chopart;  L,  incision 
for  Lisfrane;  P,  incision  for  Pirogoff. 

composed  of  all  the  structures  of  the  sole  of  the  foot.    The  edges  of 
these  flaps  are  brought  together  with  interrupted  catgut  sutures. 

In  amputating  the  left  foot  it  is  grasped  in  the  same  way  by  the 


572  LOWER  EXTREMITY. 

operator,  indicating  the  bony  guides  with  his  finger  and  thumb,  the 
incision  being  made  from  the  inner  toward  the  outer  border  of  the 
foot. 

Amputation  thkotjgh  the  Medio-taksal  Joint  (Chopaet). — 
The  tourniquet  is  placed  around  the  limb  above  the  knee-joint.  The 
right  foot,  for  example.  The  foot  extends  over  the  end  of  the  table. 
The  guide  to  the  Chopart  joint,  on  the  inner  side  of  the  foot,  is  the 
tubercle  of  the  scaphoid;  on  the  outer  side  of  the  foot  we  measure  a 
thumb's  breadth  behind  the  tuberosity  which  marks  the  base  of  the 
fifth  metatarsal  bone,  in  order  to  locate  the  outer  end  of  the  joint.  The 
foot  is  grasped  with  the  left  hand,  as  described  in  the  Lisfranc,  the 
index  finger  on  the  inner  guide,  tubercle  of  scaphoid,  and  the  thumb 
marking  the  level  of  the  joint  externally. 

As  in  the  Lisfranc,  a  short  anterior  flap  is  marked  out  by  making 
a  dorsal  incision,  curved,  with  the  convexity  forward  toward  the  toes. 
This  incision  commences  at  the  outer  border  of  the  foot  rather  in 
front  of  the  line  of  the  joint  (nearer  the  toes)  and  ends  on  the  inner 
side  of  the  foot,  likewise  in  front  of  the  line  of  the  joint  (see  Fig.  242). 
From  either  end  of  this  dorsal  incision  a  lateral  incision  is  carried 
forward,  along  either  border  of  the  foot,  toward  the  toes. 

The  short  anterior  flap  is  now  seized  and,  including  only  the  skin 
and  fat,  is  reflected  back  a  little  beyond  the  line  of  the  joint.  For- 
cibly flexing  the  foot,  the  medio-tarsal  joint  is  then  opened,  from 
within  outward,  by  inserting  the  point  of  the  knife  into  the  joint 
immediately  behind  the  tubercle  of  the  scaphoid  so  as  to  enter  be- 
tween this  bone  and  the  head  of  the  astragalus;  then,  continuing 
outward  toward  the  outer  border  of  the  foot,  the  joint  between  the 
cuboid  and  the  os  calcis  is  opened,  care  being  taken  not  to  enter, 
by  mistake,  the  joint  between  the  astragalus  and  the  os  calcis. 

Flexing  the  foot  still  more  forcibly,  and  thus  causing  the  opened 
joint  to  gape,  the  plantar  ligaments,  which  bind  the  bones  together, 
are  divided  with  the  scalpel,  and  then  a  long  knife  is  introduced 
into  the  joint  and  the  long  plantar  flap  cut  with  a  sawing  motion, 
the  edge  of  the  knife  being  applied  close  to  the  bones,  thus  separat- 
ing all  the  plantar  soft  parts  from  the  bones  as  far  down  as  the 
heads  of  the  metatarsal  bones,  where,  with  a  cut  from  within  out- 
ward, the  long  plantar  flap  is  completed. 

It  is  necessary  to  catch  the  stump  of  the  dorsalis  pedis  near 
the  inner  side  of  the  foot,  upon  the  dorsal  surface,  and  the  branches 
of  the  plantar  arch  in  the  long  posterior  flap.     The  dorsal  flap  is 


AMPUTATIONS,  EESECTIONS,  ETC.  573 

short,  and  consists  of  skin  and  fat;  the  plantar  flap  is  long,  and  in- 
cludes all  the  soft  parts  of  the  sole  of  the  foot.  The  edges  of  the 
flaps  are  united  with  several  interrupted  catgut  or  silk-worm  gut 
sutures. 

In  operating  upon  the  left  foot  it  is  grasped  hy  the  surgeon  in 
the  same  way,  the  incision  marking  out  the  dorsal  flap  being  made 
from  the  inner  toward  the  outer  border  of  the  foot. 

Owing  to  the  action  of  the  tendo  Achillis,  the  stump  which  re- 
sults is  very  apt,  after  a  time,  to  become  extended  at  the  ankle-joint; 
in  order  to  avoid  this  the  division  of  the  tendo  Achillis  has  been 
recommended.  This,  however,  helps  but  little,  and  many  surgeons 
have  discarded  this  method  of  amputation  entirely. 

Surgical  Anatomy  of  the  Ankle-joint. — The  ankle-joint  is  formed 
by  the  lower  ends  of  the  tibia  and  fibula  and  the  astragalus.  The 
lower  ends  of  the  tibia  and  fibula  are  bound  together  by  the  so-called 
interosseous  ligament,  thus  forming  an  arched  concavity  into  which 
the  articular  surface  of  the  astragalus  is  received.  The  outer  por- 
tion of  the  tibio-fibular  arch  is  formed  by  the  external  malleolus 
(lower  end  of  fibula),  which  extends  a  finger's  breadth  lower  than 
the  inner  malleolus;  the  vault  and  inner  buttress  of  the  arch  are 
formed  by  the  lower  articular  surface  of  the  tibia  and  the  inner 
malleolus.  The  articular  surface  of  the  tibia  is  broader  in  front  than 
behind. 

The  articular  surface  of  the  astragalus  presents  an  upper, 
smooth  surface,  which  slopes  downward  and  backward  and  which  is 
also  wider  in  front  than  behind,  and  is  continuous,  on  each  side,  with 
a  lateral,  smooth  facet  for  articulation  with  the  inner  and  outer 
malleoli. 

The  joint  is  provided  with  a  capsular  ligament,  which  is  de- 
scribed as  consisting  of  several  separate  portions.  Behind,  it  is 
very  thin  and  membranous,  but  is  thicker  in  front  and  upon  the 
sides. 

The  capsule  is  attached  above,  anteriorly  and  posteriorly,  to  the 
margin  of  the  tibia  and  fibula,  and  on  the  sides  to  the  margins  of  the 
inner  and  outer  malleoli;  below  it  is  attached  to  the  adjacent  rough 
surface  of  the  astragalus  and  the  os  calcis,  some  of  the  fibers  on  the 
inner  side  extending  forward  to  the  scaphoid. 

The  joint  is  provided  with  a  synovial  membrane,  which  is  applied 
to  the  inner  aspect  of  the  capsular  ligament. 


574  LOWER  EXTREMITY. 

ESAETICULATION  OF  THE  FOOT  AT  THE  ANKLE-JOINT   (SyME). — 

The  right  foot,  for  example.  The  foot  should  extend  over  the  end  of 
the  table,  and  is  grasped  by  the  operator  with  the  left  hand.  An  in- 
cision is  made  which  commences  upon  the  external  malleolus,  just 
above  its  tip,  and  which  is  carried  straight  downward  and  around  the 
sole  of  the  foot  and  thence  upward  as  far  as  the  tip  of  the  internal 
malleolus;  this  incision  reaches  to  the  bone  throughout  its  course. 
A  second  incision  is  made  which  passes  across  the  front  of  the  ankle- 
joint  through  the  skin,  joining  the  ends  of  the  first  incision. 

Having  incised  the  integument  upon  the  front  of  the  ankle, 
the  extensor  tendons,  etc.,  are  exposed;  these  are  divided  and  the 
ankle-joint  entered  by  cutting  through  the  anterior  ligament.  In 
doing  this  one  should  not,  by  mistake,  enter  the  joint  between  the 
head  of  the  astragalus  and  the  scaphoid. 

After  the  anterior  ligament  has  been  freely  divided  the  foot  is 
strongly  flexed,  and  then  the  lateral  ligament,  upon  each  side,  is 
divided  close  to  the  bone.  The  joint  now  gapes,  and  while  a  con- 
stantly increasing  traction  is  made  upon  the  foot  the  tendons  of  the 
peronei  are  cut  on  the  outer  side  and  the  tendons  of  the  tibialis 
posticus,  etc.,  on  the  inner  side. 

Cutting  with  the  edge  of  the  knife  close  to  the  bone,  the  os 
calcis  is  then  dissected  out  of  its  bed,  drawing  the  foot  first  to  one 
side  and  then  to  the  other  as  this  dissection  progresses,  and  occa- 
sionally searching  with  the  finger  for  resisting  bands,  etc.,  that  inter- 
fere with  the  enucleation  of  the  bone.  One  should  avoid  button- 
holing the  flap,  especially  as  the  back  part  of  the  os  calcis  is  reached 
and  as  the  attachment  of  the  tendo  Achillis  is  being  separated  from 
the  bone;  the  posterior  tibial  vessels  in  the  inner  side  of  the  flap 
may  also  be  avoided  by  keeping  the  edge  of  the  knife  close  to  the 
bone. 

After  the  os  calcis  has  been  thus  enucleated  from  the  soft  parts 
of  the  heel  and  the  foot  removed,  the  flap  is  turned  up  and  dissected 
away  from  the  lower  margin  of  the  tibia  and  fibula  for  a  short  dis- 
tance, in  order  to  make  way  for  the  application  of  the  saw.  A  thin 
slice  of  the  lower  end  of  the  tibia  and  the  malleoli  are  then  removed. 
The  anterior  tibial  and  the  internal  and  external  plantar  vessels  are 
ligated  and  the  anterior  and  posterior  tibial  nerves  drawn  down  and 
cut  short,  as  are  also  the  ends  of  any  divided  tendons  that  present 
themselves,  and  the  wound  then  closed  with  interrupted  catgut 
sutures. 


AMPUTATIONS,  RESECTIONS,  ETC.  575 

If  a  drain  is  used,  this  may  emerge  through  a  small  longitudinal 
incision,  which  is  made  in  the  posterior  part  of  the  flap  upon  the 
outer  side  of  the  tendo  Achillis.  Koenig  Tecommends  suture  of 
the  divided  anterior  tendons  to  the  edge  of  the  lower,  turned-up 
flap. 

Upon  the  left  foot  the  incision  would  he  made  from  the  tip  of 
the  internal  malleolus  around  the  sole  of  the  foot,  terminating  just 
ahove  the  tip  of  the  external  malleolus. 

ESAETICULATION  OF  THE  FOOT  AT  THE  ANKLE-JOINT  (PiROGOFF). 

— The  incisions  are  the  same  as  in  the  preceding  operation — the  Syme. 
After  the  ankle-joint  has  "been  freely  opened,  the  soft  parts  are 
separated  from  the  astragalus  and  the  os  calcis  backward,  beyond  the 
incision  that  passes  through  the  sole  of  the  foot,  as  far  as  the  poste- 
rior border  of  the  upper  articular  surface  of  the  astragalus.  The 
soft  parts  being  then  retracted,  the  saw  is  applied  to  the  upper  sur- 
face of  the  os  calcis  and  the  bone  cut  square  through  upon  a  plane  at 
right  angles  to  its  long  axis,  and  corresponding  to  the  incision  that 
passes  through  the  soft  parts  around  the  sole  of  the  foot. 

This  hooded  tegumentary  flap,  which  contains  the  posterior  por- 
tion of  the  os  calcis,  is  now  separated  from  the  lower  margin  of  the 
tibia  and  fibula,  working  close  to  the  surface  of  the  bones,  and  a 
thin  slice  of  the  lower  end  of  the  tibia,  together  with  both  malleoli, 
then  sawn  off.  This  section  is  made  upon  a  plane  at  right  angles 
to  the  long  axis  of  these  bones. 

The  anterior  tibial  and  the  internal  and  external  plantar  arteries 
are  ligated  and  the  corresponding  nerves  are  drawn  down  and  cut 
short. 

When  the  flap  is  brought  into  position,  the  sawn  surface  of  the 
os  calcis  and  the  sawn  surface  of  the  tibia  are  apposed;  the  edges 
of  the  wound  are  united  with  interrupted  catgut  sutures. 

If  drainage  is  desired,  it  may  be  provided  by  making  a  small 
longitudinal  opening  in  the  posterior  part  of  the  flap  along  the  outer 
side  of  the  tendo  Achillis.  If  the  traction  of  the  tendo  Achillis  upon 
the  segment  of  the  os  calcis  which  is  left  in  the  flap  is  considerable, 
the  tendon  may  be  divided  subcutaneously. 

Koenig  advises  suture  of  the  ends  of  the  cut  anterior  tendons 
to  the  edge  of  the  turned-up  flap  to  prevent  these  tendons  retracting 
up  the  leg,  and  also  to  hold  the  flap  in  position. 

The  sawn  surfaces  of  the  bones  are  usually  easily  retained  in 
apposition  by  the  bandage  and  dressings,  especially  if  the  tendo 


576 


LOWER  EXTREMITY. 


r^S 


Fig.  246. — Right  Foot,  Inner  Side.  A,  astragalus;  G,  os  calcis;  S,  sca- 
phoid; TA,  tendo  Achillis.  Dotted  lines  show  lines  of  section  through  the 
bones  in  Pirogoff  s  amputation. 


c=3 


Fig.  247. 


-Right  Foot,  Inner  Side.     Dotted  lines  show  section  through, 
bones.     Giinther's  modification. 


TA^, 


c*6& 


Fig.  248.— Right  Foot,  Inner  Side.     Dotted  lines  show  section  through 
bones.     Le  Fort's  modification. 


AMPUTATIONS,  RESECTIONS,  ETC.  577 

Achillis  has  been  divided.  Some  surgeons  prefer  to  fix  the  segment 
of  the  os  calcis  to  the  lower  end  of  the  tibia  by  driving  a  nail  through 
the  os  calcis  into  the  lower  end  of  the  tibia. 

Giinther's  Modification  of  Pirogoff's  Operation.  —  The  incision 
across  the  front  of  the  ankle  is  the  same  as  in  the  previous  opera- 
tion; the  lower  incision,  which  passes  through  the  sole  of  the  foot, 
instead  of  passing  vertically  downward  is  directed  obliquely  down- 
ward and  forward;  upon  the  inner  side  of  the  foot  this  incision  passes 
just  behind  the  tubercle  of  the  scaphoid,  and  a  similar  obliquity  is  also 
observed  upon  the  outer  side  of  the  foot,  the  incision  striking  just 
behind  the  tuberosity  of  the  base  of  the  fifth  metatarsal.  The  soft 
parts  are  dissected  back,  away  from  the  bones,  for  a  short  distance,  and, 
as  in  the  previous  operation,  the  ankle-joint  is  freely  opened  and  the 
saw  applied  to  the  upper  surface  of  the  os  calcis  behind  the  astragalus 
and  the  os  calcis  sawn  through,  not  straight  down  as  in  the  Pirogoff, 
but  obliquely  downward  and  forward  so  as  to  end  just  behind  the  an- 
terior edge  of  the  lower  surface  of  the  os  calcis. 

The  soft  parts  are  then  separated  from  the  lower  ends  of  the  tibia 
and  fibula,  and,  being  well  retracted,  the  lower  ends  of  these  bones 
are  sawn  off  obliquely  from  behind  forward  and  downward. 

The  sawn  surface  of  the  os  calcis  is  now  applied  to  the  sawn  sur- 
face of  the  tibia  without  any  rotation,  and  thus  division  of  the  tendo 
Achillis  is  avoided,  and,  further,  that  part  of  the  stump  which  sup- 
ports the  weight  and  is  applied  to  the  ground  corresponds  to  the  under 
surface  of  the  os  calcis  and  the  integument  covering  it. 

After  the  vessels  have  been  ligated  the  edges  of  the  wound  are 
brought  together  with  interrupted  catgut  sutures.  It  may  be  wise  to 
fix  the  stump  of  the  os  calcis  to  the  lower  surface  of  the  tibia  with  a 
nail,  which  is  driven  through  the  os  calcis  into  the  lower  end  of 
the  tibia,  previously  making  a  small  incision  in  the  skin  to  allow  the 
nail  to  be  introduced.  Drainage  may  be  provided  as  in  the  preceding 
operations. 

Le  Fort's  Modification  of  Pirogoff's  Amputation.  —  A  slightly 
curved  dorsal  incision  is  made  across  the  foot,  corresponding  to  the 
Chopart  joint,  commencing  on  the  outer  side  of  the  foot  one  inch 
below  and  in  front  of  the  tip  of  the  external  malleolus  and  ending  on 
the  inner  side  of  the  foot  at  the  tubercle  of  the  scaphoid.  A  second 
incision,  passing  obliquely  forward,  is  made  through  the  sole  of  the 
foot  as  in  Giinther's  operation,  uniting  the  ends  of  the  dorsal  in- 


578  LOWER  EXTREMITY. 

cision.  The  integument  is  then  dissected  back,  and  the  ankle-joint, 
under  forcible  flexion,  widely  opened  as  in  the  Pirogoff. 

The  upper  third  of  the  os  calcis,  through  a  plane  parallel  with 
the  long  axis  of  the  bone,  is  sawn  off;  this  section  through  the  os 
calcis  commences  at  the  posterior  end  of  the  bone,  after  first  sepa- 
rating the  soft  parts  and  the  tendo  Achillis  sufficiently  to  apply  the 
saw,  and  passes  forward  through  the  bone  as  far  as  the  Chopart 
joint  (articulation  between  the  os  calcis  and  cuboid).  The  foot  is 
then  removed,  leaving  the  remains  of  the  os  calcis,  with  the  tendo 
Achillis  attached,  in  the  flap.  The  lower  ends  of  the  tibia  and  fibula, 
after  proper  separation  and  retraction  of  the  soft  parts,  are  then 
sawn  off.  The  sawn  surfaces  are  apposed  and  the  wound  closed.  This 
is  a  rather  difficult  operation  to  perform. 

Amputation  of  the  Leg. — The  leg  may  be  amputated  at  any  point 
up  to  the  level  of  the  tuberosity  of  the  tibia.  With  a  view  to  the  use 
of  an  artificial  limb,  one  should  make  an  effort  to  save  the  knee-joint 
and  as  much  of  the  length  of  the  leg  as  possible. 

In  amputating  the  leg  we  may  use  flaps  of  different  length,  a 
long  anterior  and  a  short  posterior,  or  the  reverse,  and  the  flaps  may 
consist  of  the  integument  only  or  may  include  the  muscular  tissue  as 
well.  The  circular  method  may  also  be  used  here,  a  flap  of  integument 
being  turned  back  like  a  cuff  to  the  point  where  the  muscle  and  bone 
are  to  be  divided,  and  if  necessary,  owing  to  the  bulging  of  the  muscles 
of  the  calf,  the  circular  tegumentary  flap  may  be  split,  on  one  or  both 
sides,  in  order  to  facilitate  its  reflection. 

It  seems  to  me  that  lateral  skin  flaps  of  equal  length,  cut  in  such 
fashion  as  to  bring  the  suture  line  behind  the  end  of  the  bone,  is 
the  preferable  operation, — the  so-called  lateral  hooded  flap, — yet  we 
should  not  commit  ourselves  to  any  particular  method,  but  take  the 
flaps  as  best  we  can  when,  thereby,  more  of  the  length  of  the  limb 
can  be  saved. 

Amputation  of  the  Leg  with  Lateeal  Hooded  Flaps.— The 
tourniquet  is  placed  above  the  knee.  The  patient  lies  with  the  leg  pro- 
jecting over  the  end  of  the  table  and  steadied  by  an  assistant,  who 
grasps  it  by  the  foot  and  elevates  it.  We  must  first  decide  upon  the 
point  at  which  the  bones  are  to  be  divided,  and  then  make  our  flaps  ac- 
cordingly (see  Fig.  250) .  The  incision  is  commenced  on  the  front  of  the 
limb,  one  and  one-half  inches  below  the  level  at  which  the  bones  are 
to  be  divided  and  just  to  the  outer  side  of  the  sharp  anterior  border 
of  the  tibia;   from  this  point  the  incision  curves  downward  and  back- 


AMPUTATIONS,  RESECTIONS,  ETC. 


579 


ward  around  either  side  of  the  leg,  approaching  the  middle  line  on 
the  posterior  aspect  of  the  limb,  where  it  is  carried  upward,  in  the 
middle  line,  to  a  point  opposite  the  level  at  which  the  bones  are  to  he 
divided.  This  incision  extends  through  the  skin  and  subcutaneous  fat 
down  to,  but  not  including,  the  deep  fascia. 

Each  of  the  lateral  flaps  thus  marked  out  should  correspond  in 
length  to  half  the  thickness  of  the  limb,  adding  one-third  to  allow 


Fig.  249. — Amputation  of  Leg.     Hooded  flap  of  skin  and  fat  turned  back. 
Arrow  shows  level  at  which  bones  are  to  be  divided. 


for  retraction.     The  length  of  the  flap  is  measured  from  the  level 
at  which  the  bones  are  to  be  divided. 

The  edge  of  the  flap  is  seized  with  the  fingers,  and,  making 
strong  traction,  it  is  separated  from  the  deep  fascia,  taking  all  the 
subcutaneous  fat  with  it  and  cutting  with  long  sweeps  of  the  knife, 
its  edge  being  always  directed  toward  the  deep  fascia  in  order  to 
avoid  cutting  the  small  vessels  that  ramify  in  the  fat  and  supply  the 
integument.  In  reflecting  the  flap  we  should  work  evenly  around 
the  whole  circumference  of  the  limb. 


5S0  LOWER  EXTREMITY. 

After  the  flaps  have  been  turned  back  as  far  as  the  level  at 
which  the  bones  are  to  be  sawn  through,  and  while  they  are  thus  held 
by  an  assistant,  the  muscles  are  divided  with  a  long  knife,  down  to 
the  bone,  with  one  clean,  circular  sweep.  The  muscular  tissue  be- 
tween the  bones  may  be  divided  with  a  narrow,  double  edged  knife 
or  with  a  scalpel  and  the  periosteum  then  incised  to  make  way  for 
the  jaw. 

The  heel  of  the  saw  is  firmly  placed  upon  the  edge  of  the  tibia 
and,  drawing  back,  a  groove  is  made  in  which  the  saw  works  easily. 
When  the  tibia  is  partly  sawn  through  the  fibula  may  be  engaged 
in  order  to  complete  the  division  of  both  bones  simultaneously. 

The  use  of  the  three-tailed  cloth  retractor  may  be  dispensed 
with,  as  the  assistant  can  better,  with  his  hands  or  with  sharp  re- 
tractors, hold  the  divided  muscles  out  of  the  way  of  the  saw. 

While  the  bones  are  being  sawn  the  limb  is  supported  below, 
that  its  weight  may  not  prematurely  break  the  bones  before  their 
section  with  the  saw  has  been  completed. 

The  prominent  anterior  angle  of  the  tibia  may  be  sawn  off  or 
chiseled  away,  although  this  is  probably  an  unnecessary  step,  espe- 
cially if  the  flaps  are  sufficiently  long.  The  end  of  the  fibula  may 
be  cut  a  little  shorter  with  the  bone  forceps.  In  shortening  the 
fibula  one  should  not  use  the  straight  bone  forceps,  as  they  rather 
crush  and  splinter  the  shaft  of  the  bone;  it  is  better  to  do  this  by 
taking  several  bites  with  a  sharp  rongeur. 

Before  removing  the  tourniquet  the  anterior  and  posterior 
tibial  vessels  are  clamped  and  tied.  The  anterior  tibial  is  found 
upon  the  front  of  the  interosseous  membrane  between  the  bones; 
the  anterior  tibial  nerve  may  be  pulled  down  and  cut  short  at  the 
same  time.  The  posterior  tibial  vessels  are  located  in  the  back  of 
the  stump,  on  the  tibial  side  of  the  leg,  beneath  the  gastrocnemius 
and  soleus  muscles;  the  large  nerve  which  accompanies  these  vessels 
may  be  pulled  down  and  cut  short.  The  peroneal  branch  of  the 
posterior  tibial  artery,  which  is  found  just  behind  the  fibula,  should 
also  be  tied.  After  the  tourniquet  has  been  removed  any  remaining 
vessels  that  bleed  may  be  caught  and  tied.  The  edges  of  the  flaps 
are  joined  with  interrupted  catgut  sutures,  leaving  a  drain  which 
emerges  posteriorly.  When  the  suture  is  complete,  it  will  be  seen 
that  the  suture  line  is  located  behind  the  end  of  the  tibia  and  thus 
out  of  the  way  of  pressure. 


AMPUTATIONS,  RESECTIONS,  ETC.  581 

Surgical  Anatomy  of  the  Knee-joint. — The  knee-joint  is  made 
up  of  the  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  and 
the  patella.  The  lower  end  of  the  femur  is  expanded  and  rather 
euboidal  in  form,  having  two  prominent  condyles  which  project  back- 
ward beyond  the  posterior  surface  of  the  shaft  of  the  bone. 

The  inner  condyle,  when  the  femur  is  held  perpendicularly,  is 
seen  to  extend  lower  than  the  outer  and  is  also  rather  narrower  than 
the  outer.  The  inferior  and  posterior  surfaces  of  the  condyles  are 
smooth,  rounded,  and  covered  with  cartilage;  this  smooth  articular 
surface  is  also  continued  upward  upon  the  anterior  surface  of  the 
lower  end  of  the  femur,  extending  rather  higher  externally  than 
internally,  and  is  limited  externally  by  a  prominent  ridge. 

Behind,  between  the  projecting  condyles,  there  is  a  space  large 
enough  to  accommodate  the  thumb,  known  as  the  intercondyloid 
notch;  to  the  contiguous  surfaces  of  this  notch  the  crucial  ligaments 
are  attached. 

The  inner  condyle  presents  upon  its  inner  surface  a  broad  promi- 
nence, the  inner  tuberosity,  and  to  this  the  internal  lateral  ligament 
is  attached. 

The  outer  condyle  presents  upon  its  outer  surface  a  prominent 
tubercle,  which  is  located  a  little  behind  the  center,  and  to  this  is 
attached  the  external  lateral  ligament.  Immediately  below  this  tu- 
bercle there  is  a  smooth  groove  in  which  the  tendon  of  the  popliteus 
muscle  is  lodged. 

The  lower  and  posterior  portions  of  the  articular  surface  of  the 
condyles  articulate  with  the  articular  surface  of  the  tibia;  the  ante- 
rior portion  articulates  with  the  patella.  The  relation  of  these 
articular  surfaces  varies  according  to  the  position  of  the  knee-joint. 

The  upper  end  of  the  tibia  presents  a  superior  surface,  which 
is  divided  into  two  lateral  concave,  rather  ovoidal  portions,  which 
articulate  with  the  condyles  of  the  femur,  and  an  intermediate  rough 
area  which  is  marked  by  a  prominence,  the  spinous  process,  the  sum- 
mit of  which  presents  two  prominent  tubercles  for  the  attachment 
of  the  extremities  of  the  semilunar  interarticular  fibro-cartilages. 
This  intermediate  space,  in  front  and  behind  the  spinous  process,  is 
rough  for  the  attachment  of  the  semilunar  cartilages  and  the  crucial 
ligaments. 

The  anterior  surface  of  the  upper  end  of  the  tibia  presents  a 
triangular  surface,  its  base  corresponding  to  the  anterior  border  of 
the  upper  surface  of  the  tibia  and  its  apex  to  the  tuberosity  of  the 


582  LOWER  EXTREMITY. 

tibia.  The  tuberosity  of  the  tibia  gives  attachment  to  the  liga- 
mentum  patellae. 

The  patella  presents  a  smooth  posterior  surface,  covered  with 
cartilage,  which  articulates  with  different  parts  of  the  articular  sur- 
face of  the  condyles  in  different  positions  of  the  knee-joint. 

The  upper  and  lateral  borders  of  the  patella  give  attachment  to 
the  expanded  tendon  of  the  quadriceps;  the  lower  part  of  the  poste- 
rior surface,  which  is  rough,  gives  attachment  to  the  ligamentum 
patellae.  This  ligament,  which  is  attached  below  to  the  tubercle  of 
the  tibia,  fixes  the  patella  to  this  bone. 

The  anterior  surface  of  the  patella  is  smooth  and  is  covered  by 
a  fibrous  expansion  from  the  quadriceps  extensor,  and  is  separated 
from  the  integument  by  a  bursa  which,  at  times,  becomes  inflamed— 
housemaid's  knee. 

The  knee  is  provided  with  a  capsular  ligament  which  is  thin  or 
wanting  in  places,  and  is  strongly  reinforced  by  expansions  derived 
from  the  deep  fascia  (lata)  and  from  the  quadriceps  and  by  various 
accessory  ligaments. 

In  front  is  the  ligamentum  patellae.  Behind  is  the  ligament  of 
Winslow,  which  forms  the  posterior  part  of  the  capsule;  this  liga- 
ment is  strong,  and  extends  between  the  femur  and  the  tibia  and  is 
strengthened  by  bands  from  the  tendon  of  the  semimembranosus, 
which  pass  upward  and  outward  from  the  inner  tuberosity  of  the 
tibia  to  the  external  condyle  of  the  femur;  it  forms  part  of  the  floor 
of  the  popliteal  space,  and  the  popliteal  vessels  lie  close  to  it. 

The  origins  of  the  gastrocnemius,  plantaris,  and  popliteus  mus- 
cles are  intimately  connected  with  the  posterior  ligament. 

Laterally,  upon  the  inner  side  of  the  joint,  we  have  the  in- 
ternal lateral  ligament,  which  extends  from  the  tuberosity  of  the 
internal  condyle  to  the  upper  part  of  the  internal  border  of  the 
tibia,  and  upon  the  outer  side  the  external  lateral  ligament,  which 
is  attached  above  to  the  tubercle  on  the  external  condyle  and  below 
to  the  head  of  the  fibula.  These  lateral  ligaments  are  attached  be- 
hind the  center  of  the  condyles,  and  are  therefore  put  upon  the 
stretch  by  any  attempt  at  overextension  of  the  knee-joint.  The  cap- 
sule is  further  reinforced,  on  the  sides,  by  the  broad  expansions  that 
are  derived  from  the  quadriceps  extensor  and  the  fascia  lata;  these 
are  attached  to  the  sides  of  the  patella. 

Within  the  joint  are  the  ligamenta  alaria,  which  are  simply 
redundant  folds  of  the  synovial  membrane  that  are  reflected  from 


AMPUTATIONS,  RESECTIONS,  ETC.  583 

the  sides  of  the  patella;  these  are  prolonged  downward  and  back- 
ward as  the  ligamentum  mucosum,  which  is  attached  behind  to  the 
femur  in  the  intercondyloid  notch  between  the  condyles. 

The  crucial  ligaments,  two  in  number,  pass  between  the  lower 
end  of  the  femur  and  upper  surface  of  the  tibia,  crossing  one  an- 
other, and  help  to  fix  the  bones.  The  internal  passes  from  the  outer 
side  of  the  internal  condyle  downward,  backward,  and  outward,  and 
is  attached  to  the  rough  portion  of  the  upper  surface  of  the  tibia 
behind  the  spine.  The  external  extends  from  the  inner  side  of  the 
external  condyle  downward,  forward,  and  inward  and  is  attached  to 
the  rough  space  in  front  of  the  spine  of  the  tibia. 

Within  the  joint,  interposed  between  the  articular  surfaces  of 
the  femur  and  tibia,  are  the  two  semilunar  fibro-cartilages,  the  in- 
ternal and  the  external.  Placed  upon  the  upper  surface  of  the  tibia, 
they  serve  to  deepen  the  concavity  which  receives  the  articular  sur- 
face of  the  femur.  They  are  semilunar  in  form,  and  are  attached 
by  their  borders  to  the  margin  of  the  upper  surface  of  the  tibia  and 
to  the  inner  contiguous  surface  of  the  capsule;  by  their  extremities 
they  are  attached  to  the  rough  middle  portion  of  the  upper  surface 
of  the  tibia  between  the  two  articular  surfaces. 

The  synovial  membrane  of  the  knee-joint  is  very  extensive;  it 
lines  the  inner  surface  of  the  capsule  and  gives  off  a  large  pouch, 
which  extends  upward  upon  the  front  of  the  femur  beneath  the 
quadriceps  extensor;  as  the  ligamenta  alaria,  the  synovial  membrane 
is  reflected  from  the  sides  of  the  patella  and  is  continued  backward 
as  a  process,  the  ligamentum  mucosum,  to  the  back  of  the  femur, 
between  the  two  condyles,  where  it  is  attached.  The  synovial  mem- 
brane lines  both  surfaces  of  the  semilunar  cartilages  and  invests  the 
crucial  ligaments,  and  often  communicates  with  the  synovial  lining 
of  the  tibio-fibular  joint  and  with  the  bursas  adjacent  to  the  knee- 
joint.  It  gives  a  process  externally  which  is  found  between  the 
margin  of  the  external  semilunar  cartilage  and  tendon  of  the  pop- 
liteus  muscle,  forming  a  bursa  for  this  tendon.  A  pad  of  fat  is 
wedged  into  the  joint  below  the  patella,  being  covered  by  the  syno- 
vial membrane  of  the  joint  and  prolonged  into  the  ligamentum 
mucosum. 

The  Bues^e  Adjacent  to  the  Knee-joint. — The  arrangement 
of  the  bursa?  about  the  knee-joint  is  somewhat  irregular. 

Posteriorly.    On  the  outer  side:    First.    Between  the  posterior 


584  LOWER  EXTREMITY. 

part  of  the  capsule  and  the  outer  head  of  the  gastrocnemius  there 
is  a  bursa  which  sometimes  communicates  with  the  joint. 

Second.  Beneath  the  tendon  of  the  popliteus  there  is  a  bursa 
which  always  communicates  with  the  joint. 

Third.  Occasionally  there  is  a  bursa  between  the  tendon  of 
the  popliteus  and  the  external  lateral  ligament. 

Inner  side:  First.  Between  the  inner  head  of  the  gastrocnemius 
and  the  posterior  part  of  the  capsule  there  is  a  bursa  which  often 
communicates  with  the  joint  and  sends  a  process  between  the  gas- 
trocnemius and  the  semimembranosus. 

Second.  Between  the  semimembranosus  and  the  head  of  the 
tibia. 

Third.  Occasionally  between  the  tendons  of  the  semitendinosus 
and  semimembranosus. 

Anteriorly.  First.  Between  the  anterior  surface  of  the  patella 
and  the  integument. 

Second.  Between  the  ligamentum  patellae  and  anterior  surface 
of  the  tibia  (tubercle  tibia?). 

EXAKTICULATION    OF    THE    LEG    AT    THE    KNEE- JOINT    (STEPHEN 

Smith  Hooded  Flap). — The  patient  lies  upon  his  back,  with  the  leg 
overhanging  the  end  of  the  table.  One  should  remember  that  the  end 
of  the  femur  is  large  and  that  a  considerable  flap  is  required  to  cover 
it.    The  tourniquet  is  placed  above  the  knee,  high  up. 

The  incision,  which  passes  through  the  integument  and  fat  down 
to  the  deep  fascia,  commences  in  front,  one  inch  below  the  tubercle 
of  the  tibia;  from  this  point  it  curves  downward  and  backward  across 
either  side  of  the  leg,  and  behind,  near  the  middle  line,  is  carried 
upward  into  the  popliteal  space  as  high  as  the  level  of  the  knee- 
joint.  Two  lateral  flaps  with  rounded  corners  are  thus  marked  out. 
One  should  avoid  making  the  flap  scant  by  getting  well  upon  the 
posterior  aspect  of  the  leg  before  turning  the  incision  upward  into 
the  popliteal  space. 

This  tegumentary  flap,  which  includes  the  subcutaneous  fat,  is 
now  seized  with  the  fingers  and  dissected  away  from  the  deep  fascia 
with  long  sweeps  of  the  knife,  its  edge  being  directed  toward  the 
deep  fascia  so  as  not  to  cut  into  the  flap.  Considerable  traction 
should  be  applied  to  the  flap  as  it  is  being  reflected,  in  order  to  facili- 
tate its  separation  from  the  deep  fascia.  The  flap  should  be  dis- 
sected up  to  the  level  of  the  joint  all  around.  While  the  flap  is 
retracted  the  knee-joint  is  sharply  flexed  and  entered,  cutting  first 


AMPUTATIONS,  RESECTIONS,  ETC.  585 

through  the  lower  part  of  the  ligamentum  patellae;  the  blade  of  the 
knife  is  then  introduced,  flatwise,  between  the  semilunar  fibro-carti- 
lages  and  the  upper  surface  of  the  tibia,  and  the  cartilages  separated 


Fig.  250. — Right  Leg,  Outer  Side.  A,  outline  of  hooded  skin  flap  in  am- 
putation of  the  leg.  Dotted  line  shows  line  of  division  through  bones.  B, 
outline  of  skin  flap  in  Stephen  Smith  hooded  flap  for  exarticulation  at  the 
knee-joint. 

all  around  from  the  edge  of  the  upper  surface  of  the  tibia,  so  that 
they  may  be  left  attached  in  the  stump  after  the  leg  has  been  am- 
putated. 


586  LOWER  EXTREMITY. 

The  lateral  ligaments  are  cut  on  each  side,  and  with  the  limb 
still  strongly  flexed  the  attached  ends  of  the  fibro-cartilages  and  the 
crucial  ligaments  are  cut  away  from  the  upper  surface  of  the  tibia, 
and  then,  with  a  long  knife,  the  soft  parts  behind  the  joint,  the 
posterior  ligament,  popliteal  vessels,  etc.,  and  tendons  and  muscle, 
are  cut  square  through  from  within  the  joint.  The  amputation  is 
thus  complete. 

The  popliteal  artery  and  its  vein,  which  lies  upon  (superficial 
to)  it,  are  each  seized  and  tied.  They  lie  close  to  the  posterior  sur- 
face of  the  femur.  The  popliteal  nerves  are  pulled  down  and  cut 
short.  The  edges  of  the  flap  are  united  with  interrupted  catgut  su- 
tures, a  space  being  left  posteriorly  for  drainage. 

This  operation  gives  us  a  good,  broad,  fairly  flat  stump,  with 
the  suture  line  behind  the  extremity  of  the  bone.  The  reason  for 
leaving  the  fibro-cartilages  in  the  stump  is  that  they  tend  to  make  a 
better  base  to  the  end  of  the  femur. 

Transcondylar  Amputation  at  the  Knee-joint  (Carden). — 
A  long  anterior  and  a  short  posterior  flap  are  made,  the  femur  being 
divided  through  the  condyles.  Both  legs  hang  over  the  end  of  the 
table,  the  one  to  be  amputated  being  extended  and  supported  by  an 
assistant,  who  grasps  the  foot.  In  amputating  the  right  limb  the 
operator  stands  on  the  outer  side  of  the  leg  and  with  the  thumb  and 
forefinger  indicates  the  points  at  which  the  incision  commences  and 
ends. 

A  long  anterior  flap  is  marked  out  by  an  incision  which  passes 
through  the  skin  and  subcutaneous  fat  down  to  the  deep  fascia. 
This  incision  commences  at  a  point  a  little  behind  the  middle  of 
the  internal  condyle  and  upon  a  level  with  the  knee-joint;  it  passes 
down  the  inner  side  of  the  leg  as  far  as  the  tubercle  of  the  tibia, 
swings  outward  across  the  front  of  the  leg,  passing  below  the  tubercle 
of  the  tibia,  and  is  then  carried  upward  upon  the  outer  side  of  the 
leg  to  a  point  upon  the  outer  condyle  opposite  that  at  which  the 
incision  began  upon  the  inner  condyle. 

In  operating  upon  the  left  leg  the  operator  may  stand  upon  the 
inner  side  of  the  limb,  making  the  incision  from  the  outer  condyle 
around  to  the  inner.  The  corners  of  the  flap  should  be  rounded,  but 
the  flap  should  not  be  tongue-shaped. 

The  edge  of  the  anterior  flap  is  seized  with  the  fingers,  and  the 
flap,  consisting  of  the  skin  and  subcutaneous  fat,  is  dissected  away 
from  the  deep  fascia  and  reflected  as  far  as  the  lower  border  of  the 


AMPUTATIONS,  EESECTIONS,  ETC. 


)87 


patella;  in  thus  detaching  the  tegumentary  flap  the  edge  of  the  knife 
should  always  be  directed  toward  the  deep  fascia.     The  knee  is  then 


Pig. 


251.— Right  Leg.     Carden's  Amputation.     Solid  line  indicates  flaps. 
Dotted  line  shows  line  of  division  through  the  condyle. 


flexed  and  the  joint  opened  from  in  front  with  the  long  knife,  which 
first  divides  the  ligamentum  patellae  and  then  passes  straight  through 


Fig.   252.— Stump  After  Carden's  Amputation. 

the  joint,  cutting  capsule,  lateral  ligaments,  and  crucial  ligaments, 
and  emerging  through  the  structures  in  the  popliteal  space;  as  the 
knife  passes  through  the  integument  in  the  popliteal  space  the  assist- 


588  LOWEE  EXTREMITY. 

ant  should  draw  the  soft  parts  upward  toward  the  hip,  and  the  knife 
may  he  turned  somewhat  downward  in  order  that  the  posterior  flap 
may  not  he  cut  too  short,  as  the  integument  in  this  region  tends  to 
retract  very  much. 

The  soft  parts  are  then  separated  about  the  circumference  of  the 
condyles  and  retracted,  and  the  saw  applied,  the  section  being  made, 
not  above,  but  directly  through,  the  condyles  proper.  The  sharp 
edge  of  the  sawn  surface  of  the  condyles  may  be  rounded  off  somewhat 
with  a  file  or  with  a  rongeur  bone  forceps.  The  popliteal  artery  and 
vein  are  found  posterior  to  the  bone,  and  should  be  tied  separately 
and  the  popliteal  nerves  drawn  down  and  cut  short. 

The  stump  is  covered  over  by  joining  the  edges  of  the  long  ante- 
rior skin  flap  and  the  short  posterior  flap  with  interrupted  catgut  su- 
tures. It  is  wise  to  drain  the  synovial  pouch,  which  is  located  in  front 
of  the  lower  end  of  the  femur,  under  the  quadriceps  extensor,  by  in- 
troducing two  tubes,  which  reach  well  up  into  the  pouch,  emerging 
through  the  incision  on  either  side. 

Amputation  at  the  Knee-joint  (Geitti-Stokes). — The  posi- 
tion of  the  patient  is  the  same  as  described  in  Carden's  amputation.  A 
long  anterior  flap  is  marked  out  by  an  incision  commencing  upon  the 
internal  condyle  just  behind  its  middle,  and  passing  down  the  side  and 
then  across  the  front  of  the  leg  just  below  the  tubercle  of  the  tibia, 
and  thence  upward  to  a  point  on  the  outer  condyle  a  little  behind  its 
center.  The  flap  thus  outlined  is  like  the  Carden,  but  somewhat 
shorter.  The  edge  of  this  anterior  flap  is  seized  with  the  fingers  and, 
including  all  the  subcutaneous  fat,  is  separated  from  the  deep  fascia, 
cutting  with  the  edge  of  the  knife  directed  toward  the  deep  fascia  and 
constantly  making  considerable  traction  upon  the  flap.  At  the  lower 
border  of  the  patella,  the  flap  being  retracted  and  the  leg  flexed,  the 
knee-joint  is  opened  from  before  backward,  cutting  with  the  long  knife 
through  the  ligamentum  patellae,  capsule,  and  lateral  and  crucial  liga- 
ments, and  finally  through  the  posterior  ligaments  and  the  parts  in 
the  popliteal  space.  While  cutting  through  the  integument  in  the  pop- 
liteal space  the  skin  should  be  drawn  well  upward  toward  the  hip-joint 
so  that  the  posterior  flap  may  not  be  cut  too  short.  There  should  be 
a  short  posterior  flap,  one-half  to  one  inch  long. 

The  soft  parts  are  separated  from  the  lower  end  of  the  femur, 
working  with  the  edge  of  the  knife  close  to  the  bone,  to  a  point  beyond 
the  upper  limits  of  the  articular  surface;  here  a  circular  cut  is  made 
around  the  bone,  and  with  the  saw  the  end  of  the  femur  is  removed 


AMPUTATIONS,  RESECTIONS,  ETC. 


589 


parallel  with  the  plane  of  its  inferior  articular  surface.  After  the 
articular  end  of  the  femur  has  been  removed,  the  patella,  being 
surrounded  by  a  towel  to  give  a  good,  firm  grip,  is  seized  with  the  left 
hand  and  the  whole  of  its  articular  surface  sawn  off.  The  sawn  sur- 
face of  the  patella  is  then  apposed  to  that  of  the  lower  end  of  the 
femur,  to  which  it  is  fixed  by  two  chromicized  catgut  sutures,  which 
are  passed  through  drill  holes  in  the  posterior  edge  of  the  femur  and 
the  lower  border  of  the  patella.  The  patella  may  also  be  fixed  to  the 
femur  by  a  nail  driven  through  it  into  the  femur.  The  popliteal 
vessels  require  ligation.     A  tube  may  be  introduced  on  each  side 


Fig.   253.— Gritti-Stokes  Amputation.     Solid  lines  indicate  flaps, 
lines  show  section  through  femur  and  patella. 


Dotted 


to  drain  the  large  synovial  space  under  the  quadriceps  extensor  ten- 
don. The  edges  of  the  wound  are  sutured  with  interrupted  stitches  of 
catgut. 

Amputation  of  the  Thigh. — As  a  rule,  this  is  accomplished  by 
a  modified  circular  in  two — or,  better,  three — steps,  the  skin  being 
divided  upon  one  level,  the  muscles  upon  another,  and  the  bone  upon 
a  third.  A  tourniquet  is  placed  about  the  limb,  high  up,  near  the 
hip- joint. 

The  thigh  should  hang  over  the  end  of  the  table.  For  either  the 
right  or  the  left  thigh  it  is  probably  more  convenient  for  the  operator 
to  stand  upon  its  outer  side.    An  assistant  steadies  the  thigh  by  grasp- 


590  LOWER  EXTREMITY. 

ing  it  above  and  drawing  the  integument  a  little  toward  the  hip.  A 
second  assistant  may  support  the  limb  below. 

The  point  at  which  the  bone  is  to  be  divided  is  first  located,  and 
then,  with  a  sweep  of  the  long  amputating  knife,  a  circular  incision 
is  made  around  the  limb  through  the  skin  and  fat  down  to  the  deep 
fascia,  thus  marking  the  lower  limits  of  the  skin  flap.  This  circular 
incision  in  the  skin  should  be  placed  below  the  point  at  which  the 
bone  is  to  be  divided  a  distance  equal  to  half  the  diameter  of  the  limb 
at  that  point  (where  the  bone  is  to  be  divided),  adding  one-third 
more  to  allow  for  retraction. 

The  edge  of  the  skin  flap  is  seized  with  the  fingers  and  the  flap 
reflected  like  a  cuff,  separating  it  from  the  underlying  deep  fascia 
with  long  sweeps  of  the  scalpel,  its  edge  being  always  directed  toward 
the  deep  fascia  in  order  to  avoid  cutting  into  the  flap.  While  the 
flap  is  being  dissected  away  from  the  deep  fascia,  upon  the  posterior 
aspect  of  the  thigh,  the  limb  may  be  elevated  by  the  assistant. 

After  the  flap  has  been  dissected  back  to  within  one  inch  of  the 
point  at  wbich  the  bone  is  to  be  divided,  the  long  knife  is  again  taken 
and  the  muscles  are  cut,  with  a  circular  sweep,  down  to  the  bone. 
The  muscular  tissue  is  then  scraped  back  away  from  the  bone  with 
a  blunt  instrument  as  far  as  the  point  at  which  the  bone  is  to  be 
divided.  While  the  assistant  retracts  the  skin  and  muscles  with  his 
hands  or  sharp  retractors,  a  circular  incision  is  made  through  the 
periosteum  around  the  bone,  and  then,  planting  the  heel  of  the  saw 
upon  the  bone,  it  is  drawn  firmly  backward,  thus  making  a  groove 
for  itself,  and  the  bone  is  then  quickly  severed;  the  assistant  sup- 
ports the  limb  lightly  below  in  order  that  the  bone  may  not  be 
broken  before  it  is  sawn  completely  through.  The  limb  should  not 
be  so  held  by  the  assistant  as  to  jam  the  saw. 

The  femoral  and  profunda  femoris  arteries  and  veins,  which  are 
located  close  to  the  inner  side  of  the  femur,  are  tied  separately,  and 
the  tourniquet  then  removed,  after  which  any  remaining  bleeding 
points  may  be  clamped  and  tied. 

While  seeking  these  bleeding  points  only  a  limited  part  of  the 
surface  of  the  stump  need  be  exposed  at  one  time,  the  rest  being 
covered  and  compressed  with  a  hot  gauze  pad.  The  chief  bleeding 
points  are  sought  between  the  muscles.  The  sciatic  nerve,  which  is 
found  between  the  muscles  on  the  back  of  the  thigh,  is  pulled  down 
and  cut  short. 

The  edges  of  the  flap  are  brought  together  from  side  to  side, 


AMPUTATIONS,  RESECTIONS.  ETC.  591 

making  a  transverse  line,  with  interrupted  catgut  sutures.  It  is 
usually  wise  to  leave  a  drain  for  several  days.  If  the  subject  is  very 
muscular  and  the  limb  very  thick,  it  may  be  necessary  to  incise  the 
flap  on  one  side  in  order  to  facilitate  its  reflection. 

This  is  probably  the  preferable  method  of  amputating  the 
thigh.  Instead  of  the  above  described  method,  one  may  use  a  long 
anterior  and  a  correspondingly  shorter  posterior  tegumentary  flap, 
or  flaps  which  include  all  the  muscle  down  to  the  bone  as  well  as  the 
skin  may  be  used. 

Surgical  Anatomy  of  the  Hip-joint. — The  hip-joint  is  composed 
of  the  upper  end  of  the  femur  and  the  acetabular  cavity  of  the  os 
innominatum. 

The  upper  end  of  the  femur  presents  a  rounded  head  which 
represents  about  two-thirds  of  a  sphere;  it  is  smooth,  covered  with 
cartilage,  and  is  marked  in  the  apex  of  its  posterior,  inferior  quad- 
rant by  a  depression  in  which  is  attached  the  ligamentum  teres.  The 
head  of  the  femur  is  directed  upward,  inward,  and  forward. 

The  head  of  the  femur  is  joined  to  the  shaft  by  the  neck,  which 
passes  from  the  head  downward  and  outward  to  the  shaft;  the  neck 
is  somewhat  flattened  from  before  backward,  and  is  broader  at  its 
junction  with  the  shaft  than  with  the  head,  and  is  narrowest  mid- 
way between  these  points. 

The  upper  end  of  the  shaft  presents  upon  its  outer  aspect  the 
great  trochanter,  a  prominent,  square-shaped  mass  of  bone.  The 
external  surface  of  the  great  trochanter  is  continuous  with  the  ex- 
ternal surface  of  the  shaft,  and  is  marked  by  a  rough  line  that  passes 
obliquely  from  above  downward  and  forward;  to  this  line  is  attached 
the  gluteus  medius  muscle;  the  smooth  surface  below  and  behind 
this  line  is  covered  by  the  gluteus  maximus,  a  bursa  being  inter- 
posed. 

The  inner  surface  of  the  trochanter  is  applied  to  the  shaft  of 
the  bone,  except  for  its  upper,  posterior  part,  which  is  free  and 
hollowed  out  to  form  the  digital  fossa;  here  the  tendon  of  the 
obturator  externus  is  attached,  and  this  attachment  must  be  sepa- 
rated before  one  can  dislocate  the  head  of  the  femur  backward  in 
doing  a  resection  of  the  hip-joint. 

The  prominent  upper  border  of  the  great  trochanter  is  free, 
and  gives  attachment  to  the  tendons  of  the  obturator  internus  and 
gemelli  in  front  and  to  the  tendon  of  the  pyriformis  behind.  The 
anterior  border  of  the  trochanter  major  gives  attachment  to  the 


592  LOWER  EXTREMITY. 

gluteus  minimus;  its  posterior  border  is  thick  and  rounded  and 
limits  the  digital  fossa  behind. 

On  the  inner  side  of  the  shaft,  at  its  junction  with  the  neck, 
is  the  trochanter  minor;  it  is  smaller  than  the  trochanter  major, 
prominent,  and  pyramidal;  to  it  and  to  the  shaft  of  the  bone  imme- 
diately below  it  is  attached  the  ilio-psoas  muscle. 

Upon  the  front  of  the  bone,  commencing  above  and  externally 
at  the  great  trochanter  and  curving  obliquely  downward  and  inward 
and  passing  around  the  inner  side  of  the  shaft,  just  below  the  lesser 
tuberosity,  is  the  so-called  spiral  line.  This  line,  on  the  back  of  the 
bone,  runs  into  the  linea  aspera,  forming  one  of  the  arms  of  this 
prominent  ridge.  This  spiral  line  is  well  marked,  and  upon  the  front 
of  the  bone  gives  attachment  to  the  capsular  ligament. 

Upon  the  posterior  aspect  of  the  bone,  a  prominent,  rounded 
line  is  presented,  which  runs  from  the  posterior  border  of  the  great 
trochanter  downward  and  inward  to  the  lesser  trochanter;  this  is 
known  as  the  posterior  intertrochanteric  line. 

The  acetabulum  is  a  large  cup-shaped  depression  corresponding 
to  the  junction  of  the  three  portions  (pubes,  ilium,  ischium)  of  which 
the  os  innominatum  is  formed.  This  cavity  extends  downward  and 
inward  as  far  as  the  edge  of  the  obturator  foramen,  and  its  floor 
looks  downward,  outward,  and  forward;  it  is  surrounded  by  a  sharp, 
prominent  ridge  whose  summit  gives  attachment  to  the  ring-like 
cotyloid  fibro-cartilage  which  serves  to  deepen  the  cavity,  constrict- 
ing its  orifice  and  gripping  the  head  of  the  femur,  thus  assisting  in 
retaining  it  within  the  socket  of  the  joint.  In  order  to  dislocate  the 
head  of  the  bone,  in  resecting  the  hip-joint,  it  is  necessary  to  nick 
this  cotyloid  ligament. 

The  lower  portion  of  the  margin  or  rim  of  the  acetabulum,  that 
part  which  is  adjacent  to  the  obturator  foramen,  is  interrupted  by 
a  wide,  deep  notch,  the  cotyloid  notch.  In  the  recent  state  this 
notch  is  bridged  over  by  a  ligamentous  band,  the  transverse  liga- 
ment; that  part  of  the  ring-like  cotyloid  fibro-cartilage  which  corre- 
sponds to  the  notch  is  applied  to  the  upper  surface  of  the  transverse 
ligament.  The  transverse  ligament  converts  the  cotyloid  notch  into 
a  foramen,  through  which  vessels,  nerves,  etc.,  pass  into  the  hip- 
joint. 

The  floor  of  the  acetabulum  is  partly  articular  and  partly  non- 
articular;  the  articular  part  is  the  smooth,  horseshoe-shaped  surface 
which  occupies  the  periphery  of  the  cavity;  the  non-articular  portion 


AMPUTATIONS,  RESECTIONS,  ETC.  593 

is  the  rough,  depressed  area  which  occupies  the  middle  of  the  cavity 
and  is  prolonged  down  along  the  floor  to  the  site  of  cotyloid  notch; 
this  non-articular,  depressed  surface  lodges  a  mass  of  fat  and  its 
margins  give  attachment  to  the  ligamentum  teres. 

The  hip-joint  is  provided  with  a  capsular  ligament,  which  is 
attached  above  around  the  margin  of  the  acetabulum  and  transverse 
ligament  (which  completes  the  circumference  of  the  acetabulum  be- 
low); below  it  is  attached  to  the  femur;  in  front,  to  the  spiral  line 
as  far  as  the  lesser  trochanter;  behind  it  is  attached  to  the  surface 
of  the  neck  proper,  one-half  to  two-thirds  inch  above,  away  from, 
the  posterior  intertrochanteric  line.  The  capsule  is  materially 
strengthened  by  the  circular  fibers  that  are  woven  into  it  (ligament 
of  Webber). 

The  capsule  is  reinforced  by  three  auxiliary  bands  of  fibers. 
The  most  important  is  the  ilio-femoral  band,  which  is  thickest, 
widest,  and  longest;  it  is  attached  above  to  the  ilium  just  below  and 
behind  the  anterior  inferior  spinous  process  and  below  spreads  out 
and  is  attached  along  the  spiral  line,  from  the  greater  to  the  lesser 
trochanter;   it  is  known  as  the  "Y"  ligament  of  Bigelow. 

The  ischio-femoral  band  is  attached  to  the  ischium  behind  and 
below  the  acetabulum  (to  the  upper  part  of  the  groove  for  the  tendon 
of  the  obturator  externus),  and  to  the  femur  it  is  attached  at  the 
upper  part  of  the  trochanter  major  and  spreads  out  and  encircles 
the  capsule. 

The  pectineo-  or  pubo-  femoral  band  is  thin,  and  attached  to 
the  pectineal  eminence  on  the  os  innominatum  and  to  the  neck  of 
the  femur  behind  the  ilio-femoral  band,  being  incorporated  with  the 
lowermost  fibers  of  the  ilio-femoral  band. 

The  transverse  ligament  is  a  fibrous  band  that  bridges  across  the 
notch  in  the  lower  part  of  the  rim  of  the  acetabulum,  thus  convert- 
ing the  cotyloid  notch  into  a  foramen. 

The  cotyloid  ligament  is  a  complete  fibro-cartilaginous  ring 
which  is  attached  to  the  edge  of  the  bony  rim  and  the  transverse 
ligament,  encircling  the  acetabulum  and  deepening  the  cavity  and 
constricting  its  orifice. 

The  ligamentum  teres  is  an  interarticular  fibrous  band  which 
passes  between  the  head  of  the  femur  and  the  bottom  of  the  acetab- 
ulum. It  is  attached  in  the  bottom  of  the  acetabulum  to  the  mar- 
gins of  the  rough  space  and  to  the  transverse  ligament;  its  narrow 
end  is  attached  to  a  dimple  which  marks  the  apex  of  the  posterior 


594  LOWER  EXTREMITY. 

inferior  quadrant  of  the  head  of  the  femur.  It  is  usually  a  strong 
band. 

The  rough  depression  in  the  bottom  of  the  acetabular  cavity  is 
filled  in  with  a  cushion  of  fat  in  which  the  vessels  that  pass  along 
the  ligamentum  teres  to  supply  the  head  of  the  bone  are  lodged. 

The  synovial  membrane  of  the  hip-joint  lines  the  inner  surface 
of  the  capsule,  covers  the  mass  of  fat  in  the  floor  of  the  acetabular 
cavity,  and  is  thence  reflected  upon  the  ligamentum  teres  as  far  as 
the  head  of  the  femur  as  a  tubular  prolongation,  and  thus  practically 
shuts  the  teres  ligament  out  of  the  cavity  of  the  joint. 

A  large  bursa  lies  beneath  the  ilio-psoas  muscle  upon  the  front 
of  the  capsule;  this  often  communicates  with  the  joint.  Smaller 
bursas  are  located  between  the  various  tendons  and  adjoining  bony 
parts,  etc. 

The  hip-joint  is  covered  in  front  by  the  ilio-psoas  and  the  pectin- 
eus  muscles;  on  the  outer  side  by  the  glutei;  behind  by  the  gluteus 
niaximus,  pyriformis,  obturator  internus  and  gemelli,  and  quadratus 
femoris;   internally  and  below  by  the  obturator  externus. 

EXARTICULATION  OF  THE  THIGH  AT  THE  HlP- JOINT  (WYETH). — 

The  patient  lies  upon  the  back  with  the  thigh  extended  over  the  end  of 
the  table.  In  order  to  prevent  slipping  of  the  tourniquet,  which  is 
placed  about  the  thigh  for  the  purpose  of  compressing  the  femoral 
vessels  and  thus  controlling  the  hemorrhage,  two  long  pins  are  in- 
troduced through  the  soft  parts,  the  ligature  being  applied  above 
these.  The  pins  are  about  ten  inches  long  and  are  introduced  as 
follows: — 

One,  transfixing  the  soft  parts  on  the  outer  side  of  the  thigh, 
is  introduced  one  inch  below  the  anterior  superior  spine  of  the  ilium, 
and,  passing  backward  through  the  soft  parts  for  a  distance  of  about 
three  inches,  emerges  about  one  inch  below  the  crest  of  the  ilium; 
this  pin  transfixes  the  upper  part  of  the  tensor  vaginas  femoris 
muscle. 

A  second  pin  is  introduced  through  the  soft  parts  on  the  inner 
side  of  the  thigh,  one  inch  below  the  pubic  bone;  it  passes  through 
the  adductor  muscles,  and  emerges  posteriorly  one  inch  below  the 
tuberosity  of  the  ischium;  in  introducing  this  inner  pin  one  must 
avoid  injuring  the  femoral  vein.  '  The  femoral  artery  passes  into  the 
thigh  underneath  Poupart's  ligament  at  a  point  which  corresponds 
to  the  middle  of  a  line  drawn  from  the  anterior  superior  iliac  spine  to 
the  pubic  spine.    The  femoral  vein  lies  just  to  the  inner  side  of  the 


AMPUTATIONS,  RESECTIONS,  ETC. 


595 


artery.    Corks  are  applied  to  the  sharp  points  of  the  pins  after  they 
have  been  introduced  to  prevent  one's  pricking  one's  self. 

The  tourniquet  is  placed  around  the  thigh  above  the  pins,  which 
prevent  its  slipping  down.    A  pad  may  be  placed  beneath  the  tourni- 


Fig.  254. — Exarticulation  at  Hip-joint.  Wyeth  pins  in  place  to  prevent 
ligature  from  slipping.  Upon  the  outer  side  of  thigh  the  incision  reaches  to 
the  bone.  A  circular  skin  flap  has  been  turned  back  and  the  muscles  and 
blood-vessels  divided  down  to  the  bone.  Clamps  applied  to  femoral  artery 
and  vein. 


quet,  upon  the  front  of  the  thigh,  corresponding  to  the  location  of 
the  femoral  vessels,  to  still  further  secure  their  compression. 

The  operator  stands  on  the  outer  side  of  the  limb,  which  is 
supported  by  an  assistant.  "With  a  long  knife  a  circular  incision  is 
made  through  the  skin  and  fat  down  to  the  deep  fascia;    this  in- 


596  LOWER  EXTREMITY. 

cision  should  encircle  the  thigh  a  hand's  breadth  (five  inches)  "below 
the  perineum. 

With  a  stout  scalpel  a  second  incision  is  made  along  the  outer 
side  of  the  thigh.  Commencing  above  the  great  trochanter,  this  in- 
cision is  carried  downward,  upon  the  surface  of  the  trochanter  and 
along  the  outer  side  of  the  thigh,  as  far  as  the  circular  incision, 
where  it  terminates.  This  second  incision  should  reach  to  the  bone 
throughout  its  entire  extent. 

The  edge  of  the  skin  flap  which  is  marked  out  by  the  circular  in- 
cision is  seized  and  dissected  away  from  the  deep  fascia  for  a  distance 
of  about  three  inches.  At  this  point,  the  skin  flap  being  retracted,  a 
circular  cut  is  made  with  the  long  knife,  through  the  muscles,  down 
to  the  bone,  dividing  the  vessels,  the  femoral  and  the  profunda  f emoris, 
which  lie  in  front  and  internal  to  the  bone.  These  vessels  are  now 
sought,  clamped,  and  tied.  In  order  to  get  better  access  to  the  vessels 
the  muscles  may  be  scraped  downward  away  from  the  shaft  of  the 
bone  for  a  short  distance.  We  should  make  sure  of  the  femoral  artery 
and  vein  and  the  profunda  femoris  and  its  vein;  these  latter  lie  in  a 
deeper  plane  than  the  femoral  vessels.  Any  other  vessels  which  may 
be  visible,  searching  in  the  spaces  between  the  bundles  of  muscle,  are 
also  ligated. 

The  tourniquet  may  now  be  removed,  gradually  loosening  it  and 
catching  additional  vessels  as  they  bleed,  and  then  the  pins  are  with- 
drawn or  the  tourniquet  and  pins  may  be  left  until,  after  the  bone  has 
beer  enucleated  and  the  amputation  is  complete,  but  in  all  cases  the 
main  vessels  should  always  be  secured  immediately  after  the  circular 
cut  through  the  muscles  has  been  made. 

The  next  step  in  the  operation  is  the  separation  of  the  soft  parts 
from  the  shaft  of  the  bone  and  the  dislocation  of  the  head  of  the  bone 
from  its  socket.  The  soft  parts  are  retracted  and  stripped  away  from 
the  bone,  working  with  the  edge  of  the  knife  close  to  the  bone  and 
rotating  the  limb  first  inward  and  then  outward  to  facilitate  this  part 
of  the  operation.  After  the  shaft  of  the  bone  has  been  denuded  of  its 
soft  parts  up  as  far  as  the  capsule  of  the  joint,  the  joint  is  opened  by 
incising  the  capsule  and  the  cotyloid  fibro-cartilage,  and  the  head  of 
the  bone  is  then  thrown  out  of  its  socket,  cutting  or  tearing  the  liga- 
mentum  teres,  and  any  remaining  soft  parts,  and  thus  completing  the 
exarticulation. 

After  ligating  any  bleeding  points  that  show  themselves  and 
having  cut  the  nerves  short,  the  edges  of  the  skin  are  united  with  in- 


AMPUTATIONS,  EESECTIONS,  ETC.  597 

terrupted  catgut  or  silk-worm  gut  sutures,  taking,  besides,  a  few  deep 
catgut  sutures  through  the  muscle.  A  large  drainage  tube  is  intro- 
duced; this  reaches  into  the  deepest  part  of  the  wound,  into  the 
acetabular  cavity,  and  emerges  through  the  lower  end  of  the  in- 
cision. 

ExARTICULATION  AT  THE  HlP-JOINT,  WITH  PRELIMINARY  LIGA- 
TION of  the  Common  Femoral. — Amputation  at  the  hip-joint  may  be 
accomplished  with  the  loss  of  very  little  blood  if,  as  a  preliminary  step, 
the  common  femoral  artery  and  vein  have  been  ligated  high  up  within 
two  inches  of  Poupart's  ligament;  i.e.,  above  the  origin  of  the  pro- 
funda femoris  branch.  After  the  common  femoral  artery  and  vein 
have  been  tied  a  circular  incision  is  made  around  the  thigh,  five  inches 
below  the  perineum,  and  in  addition  to  this  a  longitudinal  incision, 
which  commences  above  the  trochantar  major  and  is  carried  down 
the  outer  side  of  the  thigh  just  the  same  as  in  the  preceding  opera- 
tion. The  integument  is  then  reflected,  in  the  shape  of  a  tegumentary 
cuff,  for  a  distance  of  about  three  inches,  at  which  level  the  muscles 
are  divided  layer  by  layer,  ligating  any  vessels  that  bleed  as  they  are 
met  with.  In  cutting  through  the  muscles  on  the  back  of  the  thigh 
we  meet  several  large  branches,  but  these  are  readily  secured  with 
clamps  as  they  spurt  and  are  then  ligated.  Having  cut  through  the 
muscles  down  to  the  bone,  the  soft  parts  are  separated  from  this  in  the 
usual  manner,  and  the  head  of  the  bone  turned  out  of  the  acetabulum 
and  the  amputation  thus  completed.  We  may  use  this  method  where 
tumor,  etc.,  prevent  the  use  of  the  "Wyeth  pins. 

Bisections.  Ankle-joint  (Langenbeck-Hueter). — This  opera- 
tion is  done  subperiosteally,  and  is  especially  applicable  to  cases  of 
traumatism.  The  foot  rests  with  its  inner  side  upon  a  thin  sand  bag, 
the  knee  being  slightly  flexed. 

An  incision  about  three  inches  long  is  made  along  the  posterior 
border  of  the  fibula  just  in  front  of  the  sheath  of  the  peronei  tendons; 
this  is  carried  downward  as  far  as  the  tip  of  the  malleolus,  where  it  is 
turned  upward  for  a  short  distance  along  the  front  border  of  this  mal- 
leolus. This  incision  reaches  through  the  soft  parts  and  periosteum 
to  the  bone.  The  tissues  which  cover  the  bone  are  raised  subperioste- 
ally with  an  elevator,  laying  bare  all  of  the  lower  end  of  the  fibula  and 
taking  care  not  to  injure  the  peronei  tendons,  which  are  lodged  in  the 
groove  upon  the  posterior  border  of  the  external  malleolus.  There  is 
considerable  difficulty  in  separating  the  periosteum  from  the  surface 
of  the  malleolus  below,  and  in  order  to  accomplish  this  it  may  be  neces- 


598 


LOWER  EXTREMITY. 


sary  to  resort  to  the  knife,  cutting  with  its  edge  close  upon  the  sur- 
face of  the  bone  or  else  one  may  chisel  away  a  thin  shell  of  the  cortex 
of  the  bone. 


Fh 


255.— Right  Foot,  Outer  Side.    External  incision  for  resection 
of  ankle  (Langenbeck-Hueter). 


Fig.  256.—  Right  Foot,  Inner  Side.     Anchor-shaped  incision  upon  Inner 
side   of  ankle   for   resection      (Langenbeck-Hueter). 


In  isolating  the  lower  end  of  the  fibula  on  its  inner  aspect,  corre- 
sponding to  the  attachment  of  the  interosseous  ligament  which  binds 


AMPUTATIONS,  RESECTIONS,  ETC.  599 

the  lower  ends  of  the  tibia  and  fibula  together,  care  should  be  taken 
to  stick  close  to  the  surface  of  the  bone,  so  as  to  leave  the  periosteum 
connected  with  the  interosseous  ligament. 

Now,  corresponding  to  the  upper  part  of  the  wound,  the  fibula  is 
encircled  with  a  chain  or  wire  saw  and  divided,  or  it  may  be  cut 
through  with  a  chisel.  The  upper  end  of  the  detached  fragment  is 
then  seized  with  the  bone  forceps  and  wrenched  free  from  the  remain- 
ing ligaments  (external  lateral)  which  still  hold  it.  This  gives  access 
to  the  interior  of  the  joint,  and  through  this  opening  the  upper  artic- 
ular surface  of  the  astragalus  may  be  removed  with  the  chisel  or  sharp 
spoon  and  the  joint  irrigated  and  drained. 

One  may  stop  with  this  partial  operation,  or  else  proceed  to 
do  a  complete  resection.  In  this  latter  case  the  foot  is  turned  so 
that  it  rests  upon  its  outer  side,  and  an  anchor-shaped  incision  then 
made  which  consists  of  a  cut  two  and  one-half  or  three  inches  long, 
down  the  middle  of  the  inner  subcutaneous  surface  of  the  tibia  as 
far  as  the  tip  of  the  malleolus,  and  from  this  point  additional  incisions, 
which  are  carried  upward  along  the  anterior  and  posterior  borders  of 
the  malleolus  for  a  distance  of  about  one  inch.  These  incisions  all 
reach  through  the  periosteum  to  the  bone.  In  many  cases  the  single 
longitudinal  incision  will  suffice.  Through  this  incision  the  peri- 
osteum and  soft  parts  are  separated  from  the  lower  end  of  the  tibia 
in  one  mass,  working  first  upon  the  anterior  surface  and  then  upon 
the  posterior  surface  of  the  bone,  and  avoiding  injury  to  the  tendons; 
upon  the  outer  surface  of  the  lower  end  of  the  tibia,  corresponding 
to  the  attachment  of  the  tibio-fibular  interosseous  ligament,  one 
should  work  as  close  as  possible  to  the  surface  of  the  bone. 

During  this  part  of  the  operation  the  edges  of  the  wound  are 
held  well  apart  with  blunt  retractors.  The  soft  parts  should  be 
separated  from  the  lower  end  of  the  bone  as  much  as  possible  with 
the  sharp-edged  periosteum  elevator,  but,  if  necessary,  one  may 
resort  to  the  use  of  the  knife,  keeping  close  to  the  surface  of  the 
bone,  or  may  chisel  away  a  thin  layer  of  the  cortex  of  the  bone. 
Finally,  the  internal  lateral  (deltoid)  ligaments  are  cut  close  to  the 
edge  of  the  malleolus, — it  is  better  to  separate  these  also  with  the 
elevator  or  the  chisel, — and  the  ankle-joint  is  now  open  upon  its 
inner  side.  The  lower  end  of  the  tibia  may  be  cut  through  with 
the  chain  or  wire  saw  or  chisel  upon  the  same  level  as  the  fibula  was 
divided;  it  is  then  seized  with  a  bone  forceps  and  detached  from  any 
remaining  bands  that  hold  it. 


(300  LOWER  EXTREMITY. 

The  upper  articular  surface  of  the  astragalus,  if  desirable,  may 
now  be  sawn  off  from  behind  forward  with  a  thin,  flat  saw,  taking 
care  of  the  tendons  on  the  back  and  front  of  the  joint,  or,  better, 
it  may  be  cut  away  with  the  chisel.  This  section  should  be  made 
through  such  a  plane  that,  when  the  sawn  surface  of  the  astragalus 
is  apposed  to  the  sawn  surface  of  the  tibia,  the  foot  will  be  at  right 
angles  to  the  leg.  There  is  a  tendency  to  make  the  section  through 
the  astragalus  upon  a  plane  which  would  place  the  foot  in  a  position 
of  extension  (plantar  flexion),  and  this  is  to  be  avoided. 

When  this  operation  is  performed  for  traumatism,  the  result  is 
good.  Much  of  the  bone  is  reproduced  and  the  parts  regain  almost 
their  former  contour;  any  excess  of  bone  that  is  produced  from  the 
detached  periosteum  is  usually  absorbed.  Portions  of  the  tibia,  even 
as  much  as  8  to  10  cm.,  have  been  removed  and  reproduced.  An 
ankylosed  ankle  is  the  preferable  result  after  this  operation;  the 
joints  between  the  bones  of  the  tarsus  eventually  give  considerable 
spring  to  the  foot.  When  the  operation  is  performed  for  tuber- 
culosis, frequently  no  bone  is  reproduced,  healing  fails,  and  we  have, 
as  a  result,  a  wabbly  joint,  with  sinuses. 

It  may  not  be  necessary  in  all  cases  to  do  a  complete  resection, 
since  all  of  the  parts — for  example,  the  articular  surface  of  the 
astragalus — may  not  be  diseased,  etc.  Care  should  be  exercised  in 
applying  the  dressings  to  place  the  foot  at  a  right  angle  with  the  leg 
and  turned  somewhat  outward.  It  is  probably  wise  in  all  cases  to 
drain,  at  least  for  a  few  days.  The  edges  of  the  wound  are  approxi- 
mated with  interrupted  catgut  sutures. 

With  Extirpation  of  the  Entire  Astragalus. — The  long  middle  in- 
cision on  the  inner  side  of  the  ankle  is  prolonged  downward  about  one 
inch  farther  than  described  in  the  foregoing  operation,  so  as  to  reach  to 
the  sustentaculum  tali,  and  at  its  lower  end  an  antero-posterior  incision 
is  added  which  is  about  two  inches  long  and  which  penetrates  to  the 
bone  (see  Fig.  2G0).  The  soft  parts  are  separated  forcibly  with  the 
elevator  and  the  whole  of  the  astragalus  thus  brought  into  view. 
The  joint  between  the  head  of  the  astragalus  and  the  scaphoid  is 
opened  (tuberosity  of  the  scaphoid  is  the  guide),  and  also  the  joint 
between  the  astragalus  and  the  os  calcis  (sustentaculum  tali);  after 
this  the  astragalus  is  seized  with  a  bone  forceps,  and,  twisting  and 
at  the  same  time  cutting  close  to  the  bone,  it  is  removed.  In  re- 
secting the  ankle-joint  for  tuberculosis,  if  the  astragalus  is  diseased, 
it  is  well  to  remove  this  bone  entire. 


AMPUTATIONS,  RESECTIONS,  ETC. 


601 


Ankle-joint  (Koenig). — This  is  a  satisfactory  operation,  espe- 
cially for  tuberculous  joints.  The  lower  part  of  the  leg  rests  upon  a 
sand  bag,  the  foot  being  elevated  and  turned  outward.  An  incision  is 
made  upon  the  inner  side  of  the  ankle,  commencing  an  inch  or  an  inch 
and  one-half  above  the  level  of  the  joint,  and  passing  down  along  the 
anterior  border  of  the  tibia  and  inner  malleolus  parallel  with  and  just 
internal  to  the  extensor  tendons  which  lie  upon  the  front  of  the  joint. 


MP 


Fig.  257. — E,  incisions  for  resection  of  ankle  (Koenig) ;  M.P.,  articula- 
tion between  metacarpal  bone  of  the  big  toe  and  first  phalanx;  S,  location 
of  tubercle  of  scaphoid.  Incision  for  amputation  of  big  toe  with  removal  of 
the  first  metatarsal. 

This  incision  penetrates  through  the  integument  and  periosteum  to 
the  tibia,  and  is  continued  downward  across  the  ankle-joint,  into  which 
it  opens,  and  then  curves  forward  upon  the  neck  of  the  astragalus  as 
far  as  the  tubercle  of  the  scaphoid. 

A  similar  incision  is  made  upon  the  outer  side  of  the  joint, 
commencing  above  at  the  same  level  as  the  internal  incision  and 
passing  downward  along  the  anterior  edge  of  the  outer  malleolus, 
across  the  ankle-joint,  into  which  it  opens,  and  ending  at  a  point 


602  LOWER  EXTREMITY. 

opposite  the  lower  end  of  the  inner  incision.  This  incision  runs 
parallel  with  the  outer  margin  of  the  extensor  group  of  tendons. 

Between  these  two  incisions  there  is  a  bridge  of  tissues  consist- 
ing of  integument,  anterior  tibial  vessels  and  nerve,  extensor  ten- 
dons, anterior  ligament,  and  synovial  membrane.  This  mass  of  soft 
parts  is  freely  separated  from  the  front  of  the  tibia  above  and  from 
the  astragalus  below,  as  much  as  possible  subperiosteal^  with  the 
elevator,  and  when  necessary  with  occasional  snips  with  the  scissors 
or  knife. 

Access  to  the  ankle-joint  is  now  fairly  free,  and  one  may  com- 
mence the  excision  of  the  diseased  synovial  membrane  with  mouse- 
toothed  forceps  and  scissors;  the  ends  of  the  tibia  and  fibula  and 
the  articular  surface  of  the  astragalus  may  also  be  reached  with  the 
sharp  spoon. 

If  it  is  desirable  to  resect  the  ends  of  the  bones  and  it  becomes 
necessary  to  gain  still  better  access  to  the  interior  of  the  joint,  a 
thin  shell  of  the  cortex,  carrying  the  periosteum  and  the  attach- 
ments of  the  ligaments,  may  be  chiseled  away  from  the  surface  of  the 
inner  and  also  from  the  surface  of  the  outer  malleolus,  leaving  them 
bare  and  free.  Drawing  the  soft  parts  widely  asunder  with  blunt 
hooks,  a  broad  chisel  may  be  applied,  through  the  inner  incision,  to 
the  lower  end  of  the  tibia,  and  this  may  then  be  divided;  the  frag- 
ment which  is  thus  detached  is  seized  with  bone  forceps  and  re- 
moved, cutting  the  remaining  attachments  close  to  the  bone  and 
taking  care  not  to  injure  the  tendons  which  lie  close  to  the  back  of 
the  bone  nor  the  posterior  tibial  vessels  and  nerve.  The  lower,  bare 
end  of  the  fibula  may  be  treated  in  a  similar  manner,  avoiding  the 
peroneal  tendons  in  the  groove  upon  its  posterior  surface.  In  laying 
bare  the  malleoli  one  should  try  to  separate  the  lateral  ligaments 
with  the  chisel  subperiosteal^  in  preference  to  cutting  them. 

The  articular  surface  of  the  astragalus  may  be  removed  with  the 
broad  chisel  or  with  a  narrow,  thin-bladed  saw,  the  section  being 
made  through  a  plane  which  will  allow  the  foot  to  be  placed  at  a 
right  angle  with  the  leg. 

In  most  cases  of  tuberculous  joints  when  the  astragalus  is  in- 
volved, it  is  probably  better  to  remove  this  bone  entire;  this  will 
a]so  permit  treatment  of  the  joints  between  the  astragalus  and 
os  calcis  and  the  astragalus  and  scaphoid  if  these  are  involved,  and  this 
is  frequently  the  case.  The  astragalus  is  readily  removed  through  the 
inner  incision,  first  opening  the  joint  between  the  head  of  the  astrag- 


AMPUTATIONS,  RESECTIONS,  ETC.  603 

ahis  and  the  scaphoid,  and  then  the  joint  between  the  head  of  the 
astragalus  and  the  sustentaculum  tali  of  the  os  calcis.  The  astragalus 
is  seized  with  a  lion-tooth  forceps,  and,  cutting  its  attachments  close 
to  the  bone,  it  is  twisted  free. 

Whether  the  entire  astragalus  is  removed  or  not  in  cases  of 
tuberculosis  the  whole  synovial  membrane  lining  of  the  ankle-joint 
should  be  removed  with  toothed  forceps  and  scissors;  that  part  of 
the  membrane  which  lines  the  posterior  portion  of  the  capsule  is 
difficult  to  reach,  but  its  removal  may  be  facilitated  by  drawing  the 
foot  strongly  downward  away  from  the  tibia  and  at  the  same  time 
strongly  reflecting  the  anterior  flap  or  bridge  of  soft  parts. 

Usually  there  are  no  vessels  to  tie.  Drainage  tubes  may  be  in- 
troduced on  each  side  and  the  wound  packed  with  iodoform  gauze. 
The  edges  of  the  wounds  are  brought  together  with  interrupted  catgut 
sutures,  being  left  partly  open  to  allow  for  the  drainage  tubes  and 
gauze.    The  foot  is  dressed  at  a  right  angle  to  the  leg. 

Ankle-joint  (Lauenstein). — A  very  satisfactory  method,  espe- 
cially for  tuberculous  joints.  The  knee  is  slightly  flexed,  and  the 
foot  rests  with  its  inner  surface  upon  a  thin  sand  bag.  The  in- 
cision is  placed  upon  the  outer  side  of  the  joint,  passing  through  the 
skin  and  subcutaneous  fat  and  exposing  the  external  surface  of  the 
outer  malleolus  and  the  lower  end  of  the  fibula  for  a  distance  of  about 
three  inches.  The  surface  of  the  fibula  thus  exposed  is  subcutaneous, 
and  is  included  between  the  tendon  of  the  peroneus  tertius  in  front 
and  the  tendon  of  the  peroneus  brevis  behind;  from  the  tip  of  the 
outer  malleolus  the  incision  curves  forward  and  inward  across  the  dor- 
sum of  the  foot,  terminating  just  external  to  the  tendon  of  the  pero- 
neus tertius,  which  should  not  be  cut. 

The  joint  is  now  opened  in  front  of  the  external  malleolus  by 
cutting  the  anterior  fasciculus  of  the  external  lateral  ligament,  and 
then  the  integument,  together  with  the  extensor  tendons  and  other 
soft  parts,  including  the  anterior  portion  of  the  capsular  ligament, 
are  separated  from  the  front  of  the  tibia  with  the  periosteum  elevator, 
these  soft  parts  being  meanwhile  drawn  forcibly  forward,  away  from 
the  front  surface  of  the  tibia,  with  a  blunt  hook. 

The  posterior  margin  of  the  incision  is  next  seized  and  retracted 
and  the  sheath  of  the  peroneal  tendons  opened;  these  tendons,  to- 
gether with  the  integument,  are  drawn  well  back  out  of  the  way  with 
a  blunt  hook  and  the  remaining  fasciculi  of  the  external  lateral  liga- 
ment (middle  and  posterior)  then  divided. 


604 


LOWER  EXTREMITY. 


The  foot,  being  somewhat  extended  in  order  to  relieve  the  ten- 
sion of  the  peronei  tendons,  may  now,  with  moderate  force,  be  com- 
pletely dislocated  by  rotating  it  inward  upon  its  long  axis  in  a  hinge- 
like fashion  around  the  internal  malleolus. 

All  parts  of  the  joint  are  now  accessible;  the  synovial  membrane 
may  be  dissected  away  with  a  thumb  forceps  and  scissors,  and  the 
upper  articular  surface  of  the  astragalus,  if  desired,  may  be  chiseled 
away  or  resected  with  a  thin,  flat  saw,  or,  by  extending  the  incision 
somewhat,  the  entire  bone  may  be  removed.  If  the  tibia  and  fibula 
are  diseased,  the  soft  parts  about  the  lower  ends  of  these  bones  may 
be  detached,  preferably  subperiosteal^,  with  the  elevator,  and  the  dis- 
eased portion  of  the  bones  then  resected  with  the  saw.    If  the  articular 


Fig.  258.-—  Resection  of  Ankle-joint.    Lauenstein's  incision. 

surface  only  of  the  astragalus,  and  not  the  whole  bone,  is  to  be  re- 
moved, one  should  take  care  to  make  the  section  through  the  bone  in 
such  a  plane  that,  when  the  foot  is  replaced,  the  cut  surfaces  of  the 
astragalus  and  tibia  will  permit  of  the  foot  being  placed  at  a  right 
angle  with  the  leg.  There  is  a  marked  tendency,  in  resecting  the 
articular  surface  of  the  astragalus,  to  carry  the  section  through  a  plane 
which  would  result  in  the  foot's  being  joined  to  the  leg  at  an  obtuse 
angle,  in  a  position  of  extension,  and  this  is  to  be  avoided. 

Ankle-joint,  Osteoplastic  (Mikulicz- Wladimirow).  —  The 
patient  lies  upon  the  abdomen.  A  transverse  incision  is  made 
across  the  sole  of  the  foot.  This  incision  commences  on  the  outer 
border  of  the  foot  a  finger's  breadth  behind  the  tuberosity  which 


AMPUTATIONS,  RESECTIONS,  ETC. 


605 


marks  the  base  of  the  fifth  metatarsal  bone  (little  toe),  and  ends 
on  the  inner  side  of  the  foot  at  the  tubercle  of  the  scaphoid.  From 
either  end  of  this  incision,  upon  either  side  of  the  foot  an  additional 
incision  is  carried  obliquely  upward  and  backward  across  the  lower  end 
of  each  malleolus  to  their  posterior  borders,  and  then  still  another 
incision  is  made  transversely,  just  above  the  heel,  uniting  the  ends  of 
the  two  lateral  incisions  and  dividing  the  tendo  Achillis  and  the  poste- 
rior tibial  vessels.  All  these  incisions  penetrate  to  the  bone.  The  foot 
is  now  forcibly  flexed  (dorsal  flexion)  and  the  ankle-joint  is  opened 
from  behind  and  the  lateral  ligaments  are  cut.     The  astragalus  and 


Fig.  259.— Right  Foot,  Inner  Side.  Line  of  incision  for  Mikulicz-Wladimi- 
row  osteoplastic  resection  of  the  ankle-joint.  Dotted  lines  indicate  section 
through  the  bones. 


the  os  calcis  are  then  dissected  out  of  the  mass  of  soft  parts  in  which 
they  are  located,  working  with  the  edge  of  the  knife  close  to  the  sur- 
face of  the  bones;  during  this  step  of  the  operation  the  bones  are 
forcibly  drawn,  first  to  one  side  and  then  to  the  other,  in  order  to 
facilitate  their  enucleation,  and,  working  forward,  the  joint  between 
the  astragalus  and  the  os  calcis  behind  and  the  scaphoid  and  cuboid  in 
front  is  finally  opened.  The  remaining  ligaments  and  bands  are  then 
severed  and  the  bones  removed. 

The  soft  parts  around  the  lower  end  of  the  tibia  and  fibula  are 
now  separated,  cutting  with  the  edge  of  the  knife  close  to  the  surface 


606  LOWER  EXTREMITY. 

of  the  bones,  and  a  thin  slice  of  the  lower  end  of  the  tibia,  including 
both  malleoli,  is  sawn  off. 

A  thin  slice,  including  the  articular  surfaces,  is  likewise  sawn 
off  from  the  scaphoid  and  cuboid,  so  that  when  the  foot  is  extended 
(plantar  flexion)  the  sawn  surfaces  of  the  cuboid  and  scaphoid  may 
be  apposed  to  the  sawn  surfaces  of  the  tibia  and  fibula,  the  long  axis 
of  the  leg  being  thus  prolonged  into  the  foot,  as  a  direct  line,  the 
patient  walking  upon  the  heads  of  the  metatarsal  bones  and  the 
phalanges. 

The  posterior  tibial  vessels  which  lie  behind  the  ankle-joint, 
to  the  inner  side  of  the  tendo  Achillis,  are  cut,  and  must  be  ligated. 
The  bones  may  be  retained  in  contact  with  sutures  of  chromicized 
catgut  carried  through  drill  holes,  but  this  is,  as  a  rule,  unnecessary, 
especially  if  the  foot  is  put  up  in  plaster.  The  skin  wound  is  closed 
with  interrupted  catgut  sutures. 

One  should  be  careful  that  the  integument  on  the  front  of  the 
ankle,  which  is  redundant  after  excision  of  these  bones,  does  not 
interfere  through  its  bulk,  "bunching,"  with  the  correct  apposition 
of  tho  bones.  One  may  overcome  this  tendency  by  passing  several 
quilting  sutures  through  this  mass  of  soft  parts. 

Knee-joint. — A  tourniquet  is  applied  about  the  upper  part  of 
the  thigh.  The  patient  lies  upon  the  back  with  the  leg  extended,  the 
operator  standing  upon  the  side  of  the  table  corresponding  to  the  joint 
which  is  to  be  resected. 

The  usual  incision  (Textor)  and  probably  the  best  for  most 
cases  is  convex  downward,  passing  across  the  front  of  the  joint, 
below  the  patella,  and  extending  from  the  middle  of  one  condyle  to 
a  similar  point  upon  the  other.  This  incision  should  reach  deep  to 
the  bone,  and  below  the  patella  divides  the  ligamentum  patellae. 

The  knee-joint  having  been  thus  opened,  the  limb  is  strongly 
flexed  at  the  hip  and  knee,  with  the  sole  of  the  foot  resting  upon  the 
table,  and  it  is  thus  supported  by  an  assistant.  The  lateral  ligaments 
and  the  lateral  portions  of  the  capsule  are  now  divided,  cutting  them 
close  to  the  surface  of  the  femur. 

The  knee  being  still  more  markedly  flexed,  the  crucial  ligaments 
are  divided  close  to  their  attachment  to  the  upper  surface  of  the  tibia, 
cutting  with  the  edge  of  the  knife  directed  downward,  as  if  one  would 
cut  into  the  articular  surface  of  the  upper  end  of  the  tibia;  if  the 
ligaments  are  divided  with  the  edge  of  the  knife  directed  backward, 
one  may  accidentally  cut  the  popliteal  vessels. 


AMPUTATIONS,  RESECTIONS,  ETC.  607 

The  anterior  flap,  which  includes  the  patella,  should  be  dis- 
sected back  and  retracted  sufficiently  to  allow  free  access  into  the 
synovial  pouch,  which  is  located  above  the  patella,  between  the  quad- 
riceps tendon  and  the  front  of  the  femur. 


Fig.  260.— Right  Leg,  Inner  Side.  A8,  incision  upon  the  inner  aspect  of 
the  ankle  for  resection  of  the  astragalus;  K,  Textor  incision  for  resection  of 
the  knee-joint.     Dotted  lines  indicate  planes  of  section  through  the  bones. 

With  mouse-tooth  forceps  and  blunt-pointed  scissors,  curved 
on  the  flat,  the  synovial  membrane  which  lines  the  joint  may  now  be 
entirely  resected.     If  the  bones  are  healthy,  one  may  stop  at  this 


608  LOWER  EXTREMITY. 

stage  of  the  operation  and  close  the  wound,  after  irrigating  thor- 
oughly and  providing  for  suitable  drainage  (arthrectomy). 

In  resecting  that  part  of  the  synovial  membrane  which  lines 
the  posterior  part  of  the  capsule  one  should  avoid  cutting  deeply, 
on  account  of  the  liability  to  injure  the  popliteal  vessels,  which  lie 
adjacent  to  this  part  of  the  capsule.  There  is  rather  less  danger 
of  doing  this  if  the  posterior  ligament  is  put  upon  the  stretch  by 
drawing  the  tibia  away  from  the  femur  while  this  part  of  the  syn- 
ovial sac  is  being  excised.  This  portion  of  the  synovial  membrane 
is  also  more  accessible  after  the  ends  of  the  bones  have  been  re- 
sected. 

If  the  disease  in  the  bones  is  limited  to  one  or  more  foci,  these 
may  be  thoroughly  scooped  out  with  a  sharp  spoon,  thus  avoiding 
the  resection  of  the  ends  of  the  bones.  Especially  in  children  one 
should  avoid,  wherever  possible,  the  resection  of  the  ends  of  the 
bones,  since  interference  with  the  epiphyseal  line  may  retard  very 
much  the  subsequent  growth  of  the  limb. 

The  patella  is  usually  extirpated  if  the  ends  of  the  femur  and 
tibia  are  resected,  even  if  it  is  apparently  not  diseased.  It  is  grasped 
with  double  sharp  hooks  and  excised,  cutting  with  the  edge  of  the 
knife  close  to  the  surface  of  the  bone. 

If  one  decides  to  resect  the  ends  of  the  bones,  the  lower  end 
of  the  femur  is  first  removed,  separating  the  soft  parts  back  as  far 
as  necessary,  and  working  with  the  scalpel  close  to  the  bone.  The 
end  of  the  femur,  stripped  of  its  soft  parts,  is  forced  upward,  out 
of  the  wound,  above  the  level  of  the  tibia  (hip  flexed)  and  with 
a  sharp,  broad  saw  the  section  is  made  through  the  end  of  the  bone 
from  before  backward,  commencing  by  placing  the  heel  of  the  saw 
upon  the  bone  and  making  a  groove  by  drawing  the  instrument 
firmly  backward.  The  femur  should  be  steadied  with  both  hands  of 
an  assistant  who  supports  himself  by  resting  his  elbows  upon  the 
table.  The  end  of  the  bone  should  be  forced  sufficiently  far  upward 
out  of  the  wound  so  as  to  make  the  use  of  a  towel  to  protect  the  soft 
parts  during  its  section  unnecessary.  The  piece  of  bone  resected 
must  be  of  the  same  thickness  anteriorly,  posteriorly,  and  upon  either 
side,  otherwise,  when  the  operation  is  completed,  the  limb  will  be 
found  to  be  in  a  position  of  knock-knee  or  bow-leg,  or  there  will  be 
too  much  or  too  little  extension. 

The  section  should  pass  through  a  plane  which  is  parallel  with 
the  articular  surface  of  the  bone,  and  not  at  right  angles  with  the  long 


AMPUTATIONS,  RESECTIONS,  ETC. 


609 


axis  of  the  bone,  and  therefore  in  making  the  section  one  should  dis- 
regard the  long  axis  of  the  bone,  and  rather  keep  his  eye  on  the  plane 
of  the  articular  surface. 

The  end  of  the  tibia  is  now  likewise  stripped  of  its  soft  parts  and 
projected  upward  out  of  the  wound  well  beyond  the  sawn  surface  of 


Fig.  261.— Resection  of  Knee-joint.  A,  A1,  long  axes  of  the  femur  and 
tibia;  B,  line  drawn  at  right  angles  to  the  long  axis  of  the  femur.  C,  lines 
through  the  lower  end  of  the  femur  and  upper  end  of  the  tibia  parallel  with 
the  plane  of  the  articular  surfaces.  Through  these  planes  the  section  should 
be  made  in  resecting  the  knee-joint. 


the  femur,  and  a  section  of  the  bone  removed,  as  in  the  case  of  the 
femur,  parallel  with  the  plane  of  its  articular  surface. 

At  times  it  is  necessary  to  excise  two  or  three  inches  of  the  bones 
(femur  and  tibia'  together),  but  one  should  remove  as  little  as  the  con- 
ditions present  will  permit,  especially  in  children.  The  sharp  spoon 
may  be  used  to  extirpate  foci  which  extend  into  the  substance  of  the 


610  LOWER  EXTREMITY. 

bone  beyond  the  surface  exposed  by  the  section,  and,  if  the  cortex  is 
healthy,  one  may  remove  much  of  the  medullary  portion  of  a  bone 
rather  than  sacrifice  more  of  the  length  of  the  limb  by  removing  a 
thicker  segment  of  bone. 

The  limb  should  be  now  extended  and  the  position  of  the  joint 
noted;  when  the  ends  of  the  bones  are  brought  together  there  should 
be  the  normal  slight  bowing  inward  and  a  slight  degree  of  flexion  (five 
degrees). 

If  the  position  of  the  limb  is  not  satisfactory,  one  may  remove  a 
further  section  from  one  of  the  bones  to  correct  it;  but  the  necessity 
for  this  second  section  should  be  avoided. 

The  position  of  the  bones  being  satisfactory,  all  loose,  ragged 
tissue  is  cut  away  and  any  remaining  portion  of  the  synovial  mem- 
brane that  has  been  overlooked  excised. 

In  most  cases  it  is  well  to  insert  tubes  for  drainage,  one  on  each 
side.  These  should  reach  well  up  into  the  recess  beneath  the  quadri- 
ceps muscle,  between  it  and  the  front  of  the  femur;  in  addition,  strips 
of  iodoform  gauze  may  be  packed  into  the  wound,  the  ends  emerging 
through  the  incision  on  each  side;  if  tubes  are  used,  they  should  be 
fixed  to  the  edge  of  the  skin  with  a  silk-worm  gut  stitch  to  prevent 
their  slipping  out.  The  front  part  of  the  skin  incision  is  closed  with 
interrupted  silk-worm  gut  stitches. 

If  the  limb  is  placed  in  a  good,  firm,  plaster-of-Paris  splint,  the 
ends  of  the  bones,  as  a  rule,  remain  in  good  position.  A  sharp  edge  of 
either  bone  should  not  be  left  projecting  into  the  popliteal  space  (pop- 
liteal vessels).  If  it  is  desired  to  fix  the  ends  of  the  bones  they  may 
be  joined  together  with  two  stout  chromicized  catgut  sutures  which 
pass  through  drill  holes  placed  near  the  anterior  margin  of  the  sawn 
surfaces  of  the  bones,  one  on  each  side  of  the  middle  line,  or,  after  the 
skin  has  been  sutured,  the  bones  may  be  joined  by  two  nails,  one 
driven  through  the  front  of  the  upper  end  of  the  tibia  and  reaching 
obliquely  upward  into  the  sawn  surface  of  the  femur,  and  the  other 
passing  through  the  front  surface  of  the  femur  and  reaching  down 
into  the  upper  end  of  the  tibia.  Small  incisions  may  be  made  in  the 
skin  to  allow  the  introduction  of  the  nails. 

These  accessory  measures,  for  the  purpose  of  holding  the  bones 
in  apposition,  are,  as  a  rule,  unnecessary  if  the  ends  of  the  bones  have 
been  sawn  square,  and  fit  well,  and  a  good  plaster  splint  is  applied. 
In  adjusting  the  plaster  splint  one  should  see  that  the  foot  is  slightly 
everted,  so  that  the  patient  will  not  "toe  in." 


AMPUTATIONS,  RESECTIONS,  ETC.  QH 

Before  suturing  the  wound  the  tourniquet  may  be  removed  and 
any  spurting  vessels  secured;  usually  there  are  few  or  none,  and  any 
slight  oozing  may  be  controlled  by  the  pressure  of  the  dressing. 

Instead  of  the  incision  described  above  the  knee-joint  may  be 
opened  by  an  incision,  with  the  convexity  directed  upward,  passing 
across  the  limb  above  the  upper  border  of  the  patella.  This  is  the 
reverse  of  the  incision  described  above,  and  gives  very  free  access  to 
the  synovial  pouch  under  the  quadriceps  tendon. 

Volkmann  makes  a  transverse  incision  across  the  front  of  the 
knee,  through  the  skin  down  to  the  surface  of  the  patella,  the  knee 
being  slightly  flexed  and  resting  upon  a  sand  bag;  corresponding  to 
this  incision  through  the  skin,  the  patella  is  sawn  through  trans- 
versely. To  this  may  be  added  two  lateral  incisions,  one  on  each  side 
of  the  joint  running  up  and  down.  We  then  have  an  H-shape  in- 
cision. This  incision  is  especially  adapted  to  those  cases  where  the 
disease  is  limited  to  the  synovial  membrane  alone;  so  that  after  its 
excision  the  segments  of  the  patella  may  be  sutured  with  chromi- 
cized  catgut.     This  incision  is  often  desirable  in  children. 

Hip-joint  (Langenbeck). —  This  operation  is  clone  as  much 
as  possible  subperiosteally.  The  patient  lies  upon  the  well  side  of 
the  body,  with  the  hip  and  knee  slightly  flexed.  A  longitudinal  in- 
cision is  made  over  the  outer  side  of  the  hip  four  to  five  inches  long; 
it  commences  two  or  three  inches  above  the  upper  border  of  the  great 
trochanter,  upon  a  line  corresponding  to  the  long  axis  of  the  femur, 
and  from  this  point  is  continued  straight  down  upon  the  outer  surface 
of  the  trochanter  and  ends  upon  the  upper  part  of  the  shaft  of  the 
femur;  the  incision  throughout  its  whole  length  penetrates  to  the 
bone;  that  portion  of  the  incision  which  lies  above  the  trochanter 
passes  through  the  fibers  of  the  glutei  muscles  down  to  the  surface 
of  the  ilium,  which  it  reaches  just  above  the  margin  of  the  acetabulum, 
exposing  the  capsule  of  the  joint. 

Sharp  retractors  are  inserted  deep  in  the  incision  and  the  soft 
parts  drawn  forcibly  asunder.  The  capsule  is  incised  from  the  rim 
of  the  acetabulum  downward  toward  the  great  trochanter,  the  coty- 
loid ligament,  also,  being  nicked,  or  may  be  separated  from  the  bony 
rim  of  the  acetabulum  for  a  short  distance  on  either  side  of  the  in- 
cision in  the  capsule. 

With  the  periosteum  elevator,  or,  where  necessary,  with  the  knife 
or  chisel,  the  tendons,  together  with  the  periosteum  and  the  capsule, 
are  separated  from  the  greater  trochanter  and  the  neck  of  the  femur; 


612  LOWER  EXTREMITY. 

this  should  be  accomplished  as  much  as  possible  subperiosteal^  with 
the  sharp-edged  periosteum  elevator;  but,  where  the  attachment  of 
the  parts  to  the  bones  is  very  intimate,  it  may  be  necessary  to  resort 
to  the  knife,  cutting  with  its  edge  close  to  the  surface  of  the  bone,  or 
the  chisel  may  be  used,  chipping  off  a  thin  shell  of  the  cortex,  which 
carries  the  attached  tendons  with  it.  An  assistant  rotates  the  limb 
inward  or  outward  as  may  be  necessary  to  facilitate  this  part  of  the 
operation. 


Fig.  262.— Resection  of  Hip.    Langenbeck's  incision. 

In  this  way  the  upper  end  of  the  femur  is  denuded.  Pains 
should  be  taken  to  separate  the  tendon  of  the  obturator  externus, 
which  is  attached,  in  the  digital  fossa,  upon  the  inner  aspect  of  the 
great  trochanter,  and  also  the  tendons  that  are  attached  to  the  upper 
border  of  the  great  trochanter. 

In  order  to  cut  the  ligamentum  teres  the  thigh  is  flexed,  rotated 
inward,  and  adducted,  in  this  way  partly  luxating  the  head  of  the 
bone;   a  long,  narrow  knife  is  then  introduced  into  the  joint  above 


AMPUTATIONS,  RESECTIONS,  ETC. 


613 


and  behind,  and  sweeping  downward  and  forward  across  the  head 
of  the  bone,  the  ligament  is  usually  cut.  In  operating  on  diseased 
joints  it  is,  as  a  rule,  not  necessary  to  cut  the  ligamentum  teres,  as  it 
is,  in  most  cases,  already  destroyed,  or,  at  any  rate,  readily  ruptures 
upon  forcibly  manipulating  the  joint  (adduction  and  rotation  inward). 
The  head  of  the  femur  is  then  completely  luxated  backward  by 


Pig.  263— Resection  of  the  Hip.  Anthony  White's  incision.  Commences 
anteriorly  midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
upper  border  of  the  trochanter  major  and  curves  backward  above  the  tro- 
chanter major  and  then  downward  behind  the  trochanter  for  a  distance  of 
about  two  inches. 


manipulation  (flexion,  adduction,  and  rotation  inward)  and  forced  out 
of  the  wound,  when  the  head  and  neck  may  be  readily  removed  with  a 
Gigli  or  chain  saw,  with  a  flat  saw,  or  with  a  chisel. 

Some  surgeons  make  it  a  practice  to  remove  the  trochanter  as 
well  as  the  head  and  neck  of  the  femur,  making  the  line  of  section 
through  the  shaft  of  the  bone  just  below  the  great  trochanter.     In 


614  LOWER  EXTREMITY. 

order  to  do  this  it  is  necessary  to  separate  the  periosteum,  etc.,  corre- 
spondingly lower  down  upon  the  shaft  of  the  femur.  If  the  trochanter 
is  healthy,  it  is  unnecessary  to  remove  it;  yet,  if  at  all  suspicious,  it  is 
better  to  make  the  section  through  the  bone  below  the  great  tro- 
chanter, removing  the  great  trochanter  as  well  as  the  head  and  neck, 
because  the  result  is  just  as  good,  and  many  surgeons  claim  better, 
than  when  it  is  left. 

Now,  rotating  inward  and  outward,  but  chiefly  by  extension  of 
the  limb,  pulling  strongly  upon  the  femur  and  holding  the  edges  of 
the  wound  widely  apart  to  give  us  room,  we  may  proceed  to  excise  the 
synovial  membrane,  using  long,  sharp  scissors,  curved  upon  the  flat, 
and  mouse-tooth  forceps. 

If  the  acetabulum  is  diseased,  it  may  be  curetted  with  a  sharp 
spoon  or  even  resected  with  the  chisel  and  mallet.  A  sinus  may  be 
found  leading  through  the  acetabulum  to  a  focus  within  the  pelvis,  in 
which  case  drainage  of  the  joint  may  be  combined  with  counter-drain- 
age through  an  incision  made  anteriorly  just  below  Poupart's  liga- 
ment. There  is  but  little  hemorrhage  during  the  operation;  bleed- 
ing vessels  may  be  seized  as  they  are  cut  during  the  progress  of  the 
operation. 

The  soft  parts  are  brought  together  with  interrupted  silk-worm 
gut  sutures,  which  should  pass  deep  through  the  integument,  mus- 
cles, and  periosteum,  closing  the  wound,  except  for  a  space  below 
sufficient  to  allow  the  passage  of  a  thick  tube,  which  should  reach 
upward  as  far  as  the  acetabulum  for  drainage,  or  the  wound  may  be 
packed  with  iodoform  gauze,  or  the  gauze  packing  may  be  combined 
with  the  use  of  a  tube.  Before  closing  the  wound  it  should  be  washed 
out  with  hot  bichloride  solution. 

During  the  operation  one  should  work  as  much  as  possible  with 
the  periosteum  elevator  and  chisel,  cutting  as  few  tendons  as  pos- 
sible with  the  knife.  "We  should  strive  to  keep  the  capsule  and  the 
periosteum  or  shell  of  cortex  that  is  separated  from  the  bone,  along 
with  their  attached  tendons,  hanging  together  in  one  continuous 
layer;  so  that,  when  we  are  ready  to  resect,  the  denuded  upper  end 
of  the  femur  lies  in  a  sort  of  sac  which  is  made  of  the  above  named 
structures,  and  which  all  hang  together,  continuous  with  one  an- 
other, and  it  is  out  of  this  hood  or  sac  that  we  deliver  the  upper  end 
of  the  bone  for  resection.  In  closing  the  wound  the  upper  edges  of 
the  hood  should  be  included  in  the  sutures,  except  the  part  that  is 
left  open  for  drainage. 


AMPUTATIONS,  RESECTIONS,  ETC. 


615 


Osteotomy  of  the  Femur  for  Genu  Valgum — Knock-knee  (Mac- 
ewen). — The  knee  is  somewhat  flexed,  its  outer  side  resting  upon 
a  sand  bag.  A  short  longitudinal  incision  is  made  upon  the  inner 
side  of  the  thigh  just  above  the  knee-joint.  It  is  placed  one  finger's 
breadth  in  front  of  the  tendon  of  the  adductor  magnus,  its  lower 


Fig.  264— Osteotomy  (Macewen).  A.M.,  opening  in  the  adductor  magnus 
through  -which  the  femoral  artery  (F.A.)  passes  into  the  popliteal  space. 
Arrow  indicates  point  at  which  the  chisel  is  applied  and  the  dotted  line  the 
plane  of  section  for  bow-legs  and  knock-knee. 


end  upon  a  line  which  is  drawn  around  the  lower  part  of  the  thigh 
one  finger's  breadth  above  the  upper  border  of  the  external  con- 
d}de;  or  we  may  locate  the  lower  end  of  the  incision  two  fingers' 
breadth  above  the  inner  condyle  and  one  finger's  breadth  in  front  of 
the  tendon  of  the  adductor  magnus.    The  incision  is  prolonged  upward 


616  LOWER  EXTREMITY. 

for  a  distance  of  4  cm.  and  reaches  to  the  bone  through  the  integu- 
ment, vastus  internus  muscle,  and  periosteum. 

The  periosteum  is  separated  from  the  surface  of  the  bone  over 
an  area  sufficient  to  allow  the  application  of  a  broad  chisel,  with 
which  the  bone  is  divided,  in  a  direction  outward  and  slightly  upward. 
The  line  of  fracture  does  not  pass  through,  but  just  above,  the  joint. 
The  deformity  is  then  corrected,  and  the  limb,  including  the  foot, 
placed  in  a  plaster  splint. 

It  is  not  necessary  to  chisel  through  the  entire  thickness  of  the 
shaft  of  the  femur,  but  only  far  enough  to  allow  one  to  gradually  bend 
the  bone  into  position — it  should  not  be  forcibly  fractured  or  bent  into 
position  with  a  sudden  jerk.  The  line  of  fracture  is  placed  above  the 
epiphyseal  line,  and  therefore  this  operation  may  be  done  upon  chil- 
dren and  young  people  without  interfering  with  the  natural  subse- 
quent growth  of  the  femur.  This  operation  may  also  be  done  through 
an  incision  upon  the  outer  aspect  of  the  limb  upon  the  same  level. 

Suture  of  the  Patella. — Approximation  and  fixation  of  the  frag- 
ments of  the  patella  in  case  of  fracture  with  marked  separation,  etc. 

The  failure  to  obtain  bony  union  in  fracture  of  the  patella  is 
due  to  the  interposition  of  strings  of  torn  periosteum,  etc.,  and 
blood-clot  between  the  fragments,  and  to  distension  of  the  capsule 
of  the  knee-joint  with  blood  and  serum.  These  conditions  interfere 
with  immediate  close  coaptation  of  the  fragments.  The  object  of  an 
operation  is  to  approximate  and  fix  the  fragments  and  to  evacuate 
the  knee-joint. 

A  vertical  incision  is  made  sufficiently  long  to  expose  the  frag- 
ments, the  edges  of  the  wound  being  drawn  asunder  with  sharp- 
pronged  retractors.  Each  fragment  is  then,  in  turn,  lifted  up  into 
the  wound  with  a  sharp  hook  and  its  edge  freed  from  shreds  of 
periosteum  and  blood-clot.  The  blood  is  then  turned  out  of  the 
joint  and  the  joint  irrigated  with  a  warm  saline  solution.  The  frag- 
ments are  then  brought  together  with  sharp  hooks  and  fixed  in  posi- 
tion with  two  or  more  chromicized  catgut  sutures.  These  sutures 
should  include  the  periosteum  corresponding  to  the  edges  of  the 
fragments  and  should  take  a  good,  firm  bite.  It  is,  in  most  cases, 
unnecessary  to  carry  these  sutures  through  the  bone.  If  this  should 
be  desirable,  however,  the  holes  must  be  drilled  through  the  edges 
of  the  fragments.  These  drill  holes  should  not  go  through  the  entire 
thickness  of  the  bone,  but  only  partly  through,  emerging  upon  the 
edges  of  the  fragments. 


AMPUTATIONS,  RESECTIONS,  ETC. 


617 


After  the  fragments  have  been  united  the  rents  in  the  capsule, 
fibrous  expansion  of  the  quadriceps  extensor  tendon  upon  either  side, 
corresponding  to  the  lateral  margins  of  the  patella,  may  also  be 
closed  with  several  catgut  sutures.  The  incision  in  the  skin  is  su- 
tured with  catgut  without  drainage,  an  aseptic  dressing  is  applied, 


Fig.  265. — Wiring  Patella  for  Fracture.  Shows  tear  in  capsule  upon  either 
side  of  fractured  patella.  Sutures  emerge  upon  the  edge  of  each  fragment: 
i.e.,  they  do  not  pass  entirely  through  the  whole  thickness  of  the  bone. 

and  the  limb  placed  upon  a  long  posterior  splint  with  the  foot  ele- 
vated and  the  limb  flexed  at  the  hip-joint  so  as  to  relax  the  quad- 
riceps. After  one  week  the  limb  may  be  placed  in  plaster,  still  kept 
flexed  at  the  hip,  and  at  the  end  of  four  weeks  passive  motion  may  be 
commenced. 


INDEX. 


(The  names  of  arteries,  muscles,  nerves  and  veins  are  placed  in  the  Index  under  the 
headings  "Artery,"  "Muscle,"  etc.) 


Abbe,    operation    for   stricture    of   oesophagus, 

251. 
Abdomen,  221. 
antero-lateral    wall    of,    223. 
muscles   of,    224. 
aponeuroses   of,   226. 
posterior   wall   of,    222. 
regions   of,   229. 
Abdominal   cavity,    221. 
wall,    deep    vessels   of,    228. 
superficial    vessels   of,    224. 
Abscess,    extradural,    in    middle    fossa,    56. 
appendicular,    349. 
of  breast,   incisions  for,   207. 
of  cerebellum,  56. 
temporo-sphenoidal,  57. 
Alimentary   tube,    85. 
Alveolar  process,    cleft   of,    97. 
Amputation  of  arm,   530. 
of  breast,  208. 
of  finger  at  phalango-phalangeal   joint,   519. 

at   metacarpophalangeal    joint,    52i. 
of  foot  through  medio-tarsal  joint,  Chopart, 
572. 
Pirogoff   method,    575. 
Giinther  modification,  577. 
Le  Fort  modification,   577. 
Syme  method,   574. 

through   tarso-metatarsal   joint,    Lisfranc, 
569. 
of  forearm,  526. 
of  leg,  578. 
of  penis,  485. 
of  rectum,  Kraske,  420. 

Volkmann,   407. 
of  thigh,  589. 
of  toe,  568. 
of  tongue,  172. 
Angesthesia,   cocain,  3. 
general,  1. 

incomplete,  2. 
local,  2. 

Schleich  method,   3. 
nitrous  oxide,  2. 
Anal   fascia,   488,    493. 

Analgesia    by    subarachnoid    injection    of    co- 
cain,  4,   393. 
Anastomosis,    intestinal    (see    "Intestinal   An- 
astomosis"). 
Angiotribe,  12. 
Ankle-joint,  573. 
exarticulation   of  foot  at,   574. 
Pirogoff  method,   575. 
Giinther   modification,   577. 
Le  Fort  modification,   577. 
Syme,  574. 
resection   of,   Koenig,   601. 
Langenbeck-Hueter,   597. 
Lauenstein,   603. 
Mikulicz-Wladimirow,  604. 
with    extirpation    of    astragalus,    600. 
Antrum   of  Highmore,   59. 
to  drain,   75. 
mastoid,   46. 
drilling   into,   52. 
to  open  and  drain,  52. 
Anus,   artificial,  333. 


Aorta,   arch  of,   195. 

thoracic,  200. 
Aortic  valve  (orifice),  194. 
Aponeurosis   of   abdominal   muscles,   226. 

of   external   oblique,   225-423. 
Appendicectomy,   343. 
incision,  343. 
Battle,   344. 
McBurney,   344. 
Appendicitis    accompanied    by    general,   peri- 
toneal  infection,    operation,    353. 
Appendicostomy,   354. 
Appendicular  abscess,    operation,    349. 
Appendix   vermiformis,    amputation   of,    343. 
inversion  of,  348. 

stump  of,   after  amputation,   347. 
ligation    of    stump    of,    without    inversion, 

345. 
surgical  anatomy  of,  329. 
Aqueductus   Fallopii,   51. 
Arch,  mandibular,  87. 

of  aorta,  195. 
Arches,   visceral,   87. 
Arm,  amputation  of,  530. 
Arteries  of  scalp,  20. 
Artery,  anterior  tibial,  561. 
ligation  of,  562. 
axillary,  507. 

ligation  of,  515. 
brachial,  510. 

ligation  of,  516. 
common  carotid,  141. 

ligation  of,  162. 
common   carotid,   left,   201. 
deep   epigastric,   228,   426. 
dorsalis  pedis,   561. 
external  carotid,  143. 

ligation  of,  164. 
facial,    58. 
femoral,  555. 

ligation  of,  557. 
inferior  thyroid,   146,  159-168. 

ligation  of,   161-168. 
innominate,  201. 
intercostal,    ligation   of,    213. 
internal   carotid,   35,    142. 

ligation  of,  165. 
internal  mammary,  183. 

ligation  of,  213. 
internal  maxillary,  66. 
lingual,   64,   132. 

ligation  of,   167. 
middle  meningeal,   26. 

ligation  of,  26. 
musculo-phrenic,  183-228 
obturator,  439-442. 
popliteal,   560. 
posterior  tibial,   562. 

ligation  of,   564. 
pulmonary,  205. 
radial,   512. 

ligation  of,  518. 
subclavian,    134-145. 

ligation  of,   165. 
subclavian,    left,    201. 
superior   epigastric,    183,   228. 
thyroidea  ima,   140,   159. 


(619) 


620 


INDEX. 


Artery,  temporal,  66. 

ulnar,  513. 
ligation  of,  518. 

vertebral,  146. 
Ascending  colon,   331. 
Atresia  of  facial  orifices,  95. 
Auditory   canal,    external,   48,   92. 

process,    48. 
Auricle,  48,   92. 

Auriculo-ventricular    valves    (orifices),    195. 
Axilla,    surgical   anatomy   of,    507. 
Axillary  abscess,   incision  for,   510. 

line,  184. 

vein    (see   "Artery,    axillary"). 

Back,   230. 

muscles,  231. 

of  neck,  125. 
Bardeleben  operation  for  harelip,  111. 
Bassini   operation   for   inguinal   hernia,    442. 
Battle  incision,  344. 
Bevan's    operation    for    undescended    testis, 

452. 
Beyea  operation,  241. 
Bier,    subarachnoid   injection,    4,   394. 
Big   toe,   exarticulation   of,   568. 

with   removal   of   first  metatarsal   bone,  568. 
Bile-ducts    (see    "Gall-ducts"). 
Billroth,  extirpation  of  tongue,  177. 

pylorectomy,  267. 
Bladder,    drainage   of    (see    "Suprapubic   cys- 
totomy"). 

operation    for    stone    in    (see    "Suprapubic 
cystotomy"). 

puncture,  481. 

relations   of,   477. 

surgical  anatomy   of,   476. 

suture  of  wounds  of,   19. 
Blandin's  method,   harelip,   111. 
Bone,  division  of,  6. 

suture  of,   16. 
Bottini,   prostatotomy,   504. 
Bowel,  suture  of  wounds  of,  17  (see  also  "In- 
testine,"   etc.). 
Brachial  plexus,   509. 
Branchial    arches    (see    "Visceral   arches"). 

clefts   (see   "Visceral  clefts"). 
Breast,  188. 

amputation  of,  208. 
Halsted-Meyer  method,   210. 

extirpation  of  fibroid  from,  208. 

fibroid  of,  208. 

incisions  for  abscess  of,  207. 

lymphatics  of,   189. 
Bruns   method,    formation    of   lower   lip,    118. 
Bursa?   adjacent  to   knee-joint,   583. 

Caecum,   resection  of,  338. 

surgical  anatomy  of,   329. 
Canal,    crural,    434,    439-557. 
external   auditory,   48,   92. 
Hunter's,   556. 
inguinal,  424. 
Carden  amputation  of  leg,  586. 
Cardiorrhaphy,  215. 
Carotid  artery,   common,   141. 
ligation  of,   162. 
left,  201. 
external,   143. 

ligation  of,   164. 
internal,  35,  142. 

ligation   of,  165. 
triangle,    inferior,   128. 
superior,  130. 
Castration,   464. 
Cavernous  sinus,  23,  34. 
Cavum  Meckelii,  37. 
Cerebellar  abscess,    56. 
Cerebro-spinal  fluid,  24. 


Cervical  fascia,   deep,  123. 

sympathetic,   169. 
resection  of,    170. 
surgical   anatomy   of,    169. 
Cheeks,  60. 
Chest,  fascia  of,  182. 

aspiration   (see  "Thoracentesis"). 

tapping   (see   "Thoracentesis"). 
Chest  wall,  muscles  of,  182. 

resection  of  part  of,   219. 
Cholecystectomy,  369. 
Cholecysto-colostomy,    374. 

Cholecysto-duodenostomy    with    Murphy    but- 
ton, 372. 
Cholecysto-jejunostomy,    371. 
Cholecystostomy,   365. 

with   contracted   gall-bladder,    368. 

with    uncontracted    gall-bladder,    365. 
in   single  siting,    365. 
in   two    sittings,    366. 
Cholecystotomy,  362. 
Choledocho-duodenostomy   interna,    378. 
Choledocho-lithectomy,   375. 
Choledocho-lithotripsy,    377. 
Choledochotomy,  375. 
Chopart  amputation,  572. 

joint,    567. 
Circumcision,  484. 

with  clamp,  485. 
Clavicular  region,   186. 
Cleft  of   alveolar  process,   97. 

palate,  98. 
operation    for,    112. 
Clefts,   lateral  nasal,   101. 

median  of   upper   lip,   100. 

oblique  facial  clefts,  91,  101. 

of  lower  lip,   lower  jaw,   and  tongue,   103. 

orbito-nasal    (see    "Oblique    facial    clefts"). 

transverse   facial,   92,   103. 

visceral,  87. 
Cocain  anaesthesia,  3. 

sterilization,  5. 

subarachnoid     injection     of,     4     (see     also 
"Lumbar   puncture,"    393). 
Coccyx,  398. 
Colles's  ligament,  423. 

Colon,  resection  of  (see  "Resection  of  Caecum 
and    "Sigmoid    flexure"). 

surgical   anatomy   of,   331. 
Colostomy,  333. 

Maydl  method,  336. 
Common  bile-duct,   285,   357. 

operations  upon,  375. 

removal  of  calculi   from,   375. 

surgical  anatomy  of,   357. 
Congenital  deformities  of  face,  85,  94. 
classification  of,  95. 

hernia,   inguinal,   429,   430,   437,   Fig.   180. 
operation  for,   447. 
Conjoined   tendon,   425. 
Connell  suture,  300. 
Conus  terminalis,   236. 
Cooper,   pubic   ligament  of,   431,   433,   438. 
Corning,    spinal   injection,   393. 
Corpora  cavernosa,  481. 
Corpus   spongiosum,   481. 
Costal   cartilages,   181. 
Costo-coracoid    membrane,    188,    508. 
Cotting  operation,   569. 
Cowper's  gland,   490. 
Craniectomy,    30. 
Craniotomy,  linear,  30. 
Cribriform  fascia,   422,   431,   554. 
Cricoid  cartilage,   137. 
Crico-thyroid  membrane,  137. 
Crico-tracheotomy,  148. 
Crural  canal,   434,  439,  557. 

ring,  434,  439. 
Cushmg  suture,  18. 


INDEX. 


621 


Cushing    suture,    extirpation    Gasserian    gan- 
glion, 41. 
Cystic  duct,  357. 
Cystotomy,  suprapubic,  478. 

Dawbarn,    inversion    of    stump    of    appendix, 

347. 
Dartos,   457. 

"Dead  space,"  287,  297. 
Deformities  of  face,   congenital,   85,  94. 
classification   of,   95. 
in  which  first  visceral  arch  is  concerned, 

103. 
in  which  frontal  plate  is  concerned,   96. 
Deltoid   flap,   exarticulation  of  arm  at  shoul- 
der-joint, 538. 
Depressed    fracture    of   skull,    trephining   for, 

24. 
Descending   colon,   anatomy  of,   332. 
Development  of  ear,  47. 
Diaphragm,  184,  221. 

uro-genital,  490. 
Dieffenbach   Wellenschnitt,    108,   121. 

resection  of  rectum,  410. 
Dieffenbach-Jaesche   operation   for   lower   lip, 

117. 
Dilatation  of  sphincter,   401. 
Diploe,   21,   22. 
Division  of  bone,  6. 

of  soft  parts,  5. 
Dorsal  section,  482. 

Jtoser  method,  483. 
Douglas,   semilunar  fold  of,  227. 
Doyen  forceps,  275. 
Drum  of  ear,  48,  49,  92. 
Dubrueil,   exarticulation   of  hand,    525. 
Duct,   common  bile-,  285. 

cystic,   357. 

ejaculatory,  458. 

hepatic,   357. 

pancreatic,  285,  358,  380. 

Santormi,  381. 

Stenson's,  61-65. 

tear-,  91. 

thoracic,  201. 

Wharton's,   63,  131. 

Wirsung,  (see  "Pancreatic  duct") 
Ductus   communis   choledochus,   357. 
Duodenotomy    for   impacted    gall-stone,    377. 
Duodenum,  284. 
Dura  mater,   22. 

of  spinal  cord,  236. 

sinuses  of,  23. 

Ear,  development  of,  47. 
middle.  49. 

surgical  anatomy  of,  47. 
Ear-drum,  48,  49,   92. 
Edebohls,   decortication  of  kidney,  475. 
inversion  of  appendix,  348. 
nephropexy,  470. 
Ejaculatory   ducts,    458-499. 
Elbow,  space  in  front  of,  511. 
Elbow-joint,  exarticulation  of  forearm  at,  529. 
resection  of,  543. 
surgical  anatomy  of,  527. 
End-to-end   anastomosis,    large  intestine,   339. 
small  intestine,  296. 
Connell  method,  300. 
Mounsell  method,   297. 
with  Laplace  forceps,  305. 
with  Murphy  button,  303. 
with  O'Hara  forceps,  307. 
with  suture,  296. 
End-to-side,    lateral   implantation    (intestine), 

341. 
Enterectomy,  293. 

Entero-anastomosis    (see    "Intestinal    anasto- 
mosis,"   etc.). 


Enterorrhaphy,  288. 
Epididymis,  458. 

Esmarch,   exarticulation  of  arm  at  shoulder- 
joint,  536. 
Esmarch's    bandage   and    constrictor,    7. 
Estlaender,   thoracectomy,    219. 
Estlaender's   method,    restoration    of   lip,    120. 
Ethyl  chloride,  3. 
Eustachian  tube,  48,  51,  62. 
Exarticulation  of  arm  at  shoulder-joint,   del- 
toid flap,  538. 
Spence  method,  534. 
with  Esmarch  constrictor,   536. 
of  big  toe,  568. 

with  removal  of  metatarsal  bone,  568. 
of  finger,  519. 

at  metacarpo-phalangeal  joint,   521. 
of    foot    at    ankle-joint,     Pirogoff    method, 
575. 
Giinther  modification,  577. 
Le  Fort  modification,  577. 
Syme  method,   574. 
of    forearm  at  elbow-joint,  529. 
of  hand,   Dubrueil,  525. 

at    carpo-metacarpal    articulation,    522. 
of  leg   at   knee-joint,    Carden,    586. 
Gritti-Stokes,  588. 
Stephen  Smith,  584. 
of  little  toe,  568. 
Exarticulation  of  thigh  at  hip-joint  (Wyeth's 
pins),  594. 
with  preliminary  ligation  of  common  fem- 
oral,  597. 
of  toes,   568. 
Excision  of  joints   (see   "Resection"). 
Extradural  abscess,   56. 

Face,   classification  of  deformities  of,   95. 
congenital  deformities  of,  85,  94. 
in  which  first  visceral  arch  is  concerned, 

103. 
in    which   frontal    plate   is   concerned,    96. 
development  of,  85. 
side  of,  64. 
skeleton  of,   58. 
surgical  anatomy  of,  57. 
Facial  cleft,   oblique,   91,   101. 

transverse,   92,   103. 
Falciform  process,   431,   554. 
Fallopii,  aqueductus,  51. 
Fascia,  anal,  488,  493. 
cremaster,  457. 

cribriform   (cribrosa),  422,  431,  554. 
deep  cervical,   123. 

connective    tissue    spaces    beneath,    124. 
deep  perineal,   490,   499. 
endoabdominalis,   227. 
endothoracica,   182,   184,   222. 
iliaca,  227,  234,  432,  438. 
lata,  431,  551,  554. 
iliac  portion  of,  431. 
pubic  portion  of,   431. 
lumbar,  233. 
pectineal,  438. 
pelvic,  227,  492. 
perineal,  deep,  490. 

superficial,  487. 
spermatic,  422,  457. 
superficial  of  groin,  421. 
temporal,  20. 

transversalis,  227,  425,  428. 
Fasciae  of  chest,  182. 

of  thorax,  182. 
Fauces,  isthmus  of,  61. 
Femoral  hernia,  434,  439. 
operation  for,  451. 
region,   431,    437. 
anterior,  554. 
from  within  abdomen,  437. 


622 


INDEX. 


Femoral  sheath,  433,   439,   556. 

space,  433,  438. 
Fenger's  incision,  246. 
Filurn  terminate,  236. 
Finger,   exarticulation  of,  519. 

at  metacarpophalangeal  joint,   521. 
Finney  operation,  253. 
Fissure  in  ano,  400. 
Fistula  in  ano,  401. 

operation  for  complete,   402. 
for  incomplete,  403. 
Foot,  amputation  of,  Chopart,  572. 
Lisfranc,  569. 

exarticulation  of,  Gunther,  577. 
Le  Fort,  577. 
Pirogoff,  575. 
Syme,  574. 

surgical  anatomy  of,  566. 
Foramen  lacerum  medium,  32. 

obturator,  439. 

ovale,  32. 

rotundum,  34,   69. 

spinosum,   34. 
Forcipresure,  12. 

Forearm,   amputation  through,  526. 
Forebrain,  vesicle  of,  86. 
Fossa  cruralis,  437. 

ischio-rectal,  488. 

spheno-maxillary,   68. 

zygomatic,    67. 
Fovea  inguinalis  externa,  435. 

inguinalis  interna,   437. 

supravesicalis,   43 1. 
Fowler,  pleurectomy,  219. 
Frontal  plate  or  process,  88,  89,  92. 

sinus,  22. 
trephining  of,   31. 

Gall-bladder,  aspiration  of,  362. 
excision   of    ('-Cholecystectomy"), 
incision  into    (see   "Cholecystotomy"). 
operations  upon,  362. 
surgical  anatomy  of,  356. 
Gall-duct,      common      (see      "Common      bile- 
duct"). 
Gall-ducts,    operations   upon,   375. 

surgical  anatomy  of,   357. 
Ganglion,  Meckel's,  70. 
Gasserian,   35. 
extirpation    of,    Hartley-Krause,    37. 
Cushing  method,   41. 
Rose-Andrews,   42. 
Gasserian   ganglion    (see    "Ganglion"). 
Gastrectomy,   266. 
complete,    Schlatter,  2S0. 
partial,  266. 
Billroth,   267. 
Hartmann,  274. 
Kocher,  271. 
Mayo,  278. 
Gastric  ulcer,  infolding  for,  246. 
for  haemorrhage  from,   248. 
for  perforation  of,  262. 
Gastro-duodenostomy,   313. 
Finney,  253. 
Kocher,  271. 
Gastro-enterostomy,  312. 
Gastro-gastrostomy,   264. 
Gastrojejunostomy,   313. 
anterior,  313. 
Carle,   321. 

Jaboulay    and    Braun    modification,    319. 
posterior,   317. 
Czerny,  325. 
Roux,  326. 
von  Hacker,  317. 
"vicious  circle"    after,   319. 
with   Laplace  forceps,   324. 
■with  McGraw  rubber  suture,  321. 


Gastrojejunostomy,  with  Murphy  button,  320. 
with  O'Hara  forceps,   324. 
Woelfler,   313. 
Gastroplasty,  263. 
Gastroplication,   243. 
Gastrorrhaphy,   262. 
Gastrostomy,   255. 
Kader,  261. 
Ssabanajew  and  Franck,   257. 

Robson  modification,   258, 
von  Hacker,  255. 
Witzel,  259. 
Gastrotomy,   246. 
for  bleeding  ulcer,  248. 
for  foreign  body,  246. 
for  stricture   oesophagus,    251. 
Gimbernat's  ligament,  424,  438. 
Gland,   Cowper's,  490. 
mammary,  18S. 
parotid,   65. 
prostate,  491-496. 
sublingual,  63. 
submaxillary,   131. 
thyroid,  139. 
Gluteal  region,  551. 
Goiter,   operation  for,  157. 
Gritti-Stokes   amputation   of   leg,    588. 
Groin,   lymphatic  glands  of,  422. 
superficial  fascia  of,  421. 
surgical  anatomy  of,  421. 
Gubernaculum  of  Hunter,   428. 
Gunther  modification  of  Pirogoff  amputation, 

577. 
Hagedorn   operation   for  harelip,   108,   110. 
Halsted  operation  for  inguinal  hernia,  44S. 

suture,   18. 
Halsted-Meyer    amputation    of   breast,    210. 
Hand,   exarticulation  of,   at  carpo-metacarpal 
joint,   522. 
exarticulation  of,  Dubrueil,  525. 
incision  into,  515. 
nerve-supply  of,   515. 
surgical  anatomy  of,   514. 
Harelip,  91,  96. 
Bardeleben's  operation  for,  111. 
Blandin's  operation  for,   111. 
Hagedorn's  operation   for,   10S,   110. 
Malgaigne  operation  for,  106. 
Mirault  operation  for,  107. 
Nelaton  operation  for,  105. 
operations  for,  103. 
complete,  107. 

double,      with      advanced     intermaxillary 
process,   110. 
without    advanced    intermaxillary    proc- 
ess, 109. 
incomplete,  105. 

single    complete,    with    cleft    of    alveolar 
process    and    advancement    oi     inter- 
maxillary  bone,    109. 
von  Graefe  operation  for,  105. 
Hartley   chisel,   27. 
Hartley-Krause  operation,   37. 
Hartmann  forceps,   275. 

gastrectomy,  274. 
Head,   20. 

surgical   anatomy   of,    20. 
Heart,  192. 
outlines  of,   upon  chest  wall,  193. 
suture  of   wounds  of,   215. 
Heinecke-Mikulicz,   pyloroplasty,   252. 
Hemorrhage,  6. 
artificial  arrest  of,  7. 
control   of,    by  chemical  agents,   11. 
by  digital   compression   in   the   wound,    11. 
by  digital     compression    of    main    vessels 

proximal   to  wound,   9. 
by  direct  means,  10. 
by  forcipressure,   12. 


INDEX. 


623 


Hemorrhage,  control  of,  by  heat  and  cold,   10. 
by  indirect   means,    7. 
by   ligature,    12. 
by  mechanical    means,    11. 
by  position,  9. 
by  preliminary   ligation,    9. 
by  suture,  12. 
by  tamponade,  11. 
by  torsion,  12. 

through  nervous  system,   10. 
with  Esmarch  bandage,   etc.,  7. 
intracranial,    trephining   for,    26. 

from  middle  meningeal,   26. 
natural  arrest  of,  7. 
Hemorrhoids,    401-403. 
operations  for,  403. 
clamp  and  cautery,   405. 
ligation  and  excision,  404. 
Henle's   spine    (see    "Spina   supra   meatum"). 
Hepatectomy,  360. 
Hepatic  duct,  357. 
Hepatotomy,  359. 
Hernia,  421. 
femoral,  434,  439. 
operation   for,  451. 
'    inguinal,  427. 

acquired,   430,   Fig.   181. 
Bassini  operation  for,   442. 
congenital,  429,  430,  437,  Fig.  180. 

operation  for,   Bassini,   447. 
direct  (see  "H.,   internal"), 
external    or    oblique,    427,    429     (see    also 
"Fovea    inguinalis    externa,"    435). 
operation  for,  Bassini,  442. 
Halsted's  operation  for,  448. 
indirect  (see  "H.,   external"), 
infantile  or  encysted,   430. 
internal     or     direct,     427,     429     (see     also 

"Fovea    inguinalis    interna,"    437). 
operation   for,  Bassini,   448    (see   also   Hal- 
sted's,   above), 
oblique    (see   "H.,   external"), 
strangulated,   operation   for,   439. 
Herniotomy,  439. 
Highmore,   antrum  of,  59. 
operation  to  drain,  75. 
Hip-joint,    relations   of   parts   behind,    552. 
exarticulation   of   thigh   at,    594. 
with    preliminary    ligation    common    fem- 
oral, 597. 
Wyeth  method,  594. 
resection  of,   Langenbeck,  611. 

Anthony   White   incision,    613,    Fig.   263. 
surgical  anatomy  of,  591. 
Hunter,   gubernaculum  of,  428. 
Hunter's  canal,   556. 
Hydrocele,  open  operation  for,  461. 
puncture  and  injection,  460. 
retroversion  of  tunica  vaginalis,  463. 
Volkmann  operation,   461. 
von  Bergmann  operation,   462. 
Winkelmann   operation,    463. 
Hyoid  bone,  135. 

Idiocy,   craniectomy  for,   30. 
Ileo-colostomy,   339,   341. 

end-to-end,  339. 

end-to-side,   341. 

lateral    (side-to-side)    anastomosis,    340. 

without  resection  of  caecum,  341. 
Ileum,  285. 
Iliac  fascia  (see  "Fascia  iliaca"). 

portion  of  fascia  lata,  431. 
Ilio-pectineal  ligament,  379,  433. 
Ilio-psoas  space,  433. 
Inferior  maxilla  (see   "Lower  jaw"). 
Inferior  maxillary  branch  of  fifth  nerve  (see 

"Fifth    nerve"). 
Infraclavicular  region,  187. 


Infrahyoid  region,  135. 
Infundibular  process,  425,  426,  428-435. 
Infusion,    intravenous,   549. 
Ingrowing   toe-nail,   operations  for,   569. 
Inguinal  canal,  424. 
hernia   (see    "Hernia"), 
region,   422. 

from  within  abdomen,   434. 
ring,   internal,   425,   426. 
external,  423. 
Innominate  artery,  201. 
Intermaxillary  bone,  92. 

Intestinal    anastomosis,    large    intestine,    end- 
to-end,   339. 
end-to-side,  341. 
lateral,  340. 
side-to-side,  340. 
small  intestine,  end-to-end,  296. 
Connell  method,   300. 
Mounsell   method,   297. 
with  Laplace  forceps,   305. 
with  Murphy    button,    303. 
with  O'Hara  forceps,   307. 
with  suture,   296. 
lateral,   with  Laplace  forceps,   312. 
with  McGraw    rubber    suture,    312. 
with  Murphy  button,    311. 
with  O'Hara  forceps,  312. 
with  suture,    310. 
side-to-side   (see   "lateral"). 
Intestinal  clamp  or  compressor,  293,   Fig.  124. 
Intestine,   large,    blood-supply  of,   332. 
operations   upon,   333. 
surgical  anatomy,   329. 
resection  of  part  of,  341. 
small,   blood-supply  of,   287. 

operations  upon,  288. 
resection   of,   293. 
surgical  anatomy  of,  284. 
suture      of      wounds      of      (see      "Enteror- 
rhaphy"). 
Intracranial   hemorrhage,   26. 

trephining  for,  26. 
Intravenous  infusion,   549. 
Ischio-rectal  fossa,  488. 

region,    488. 
Isthmus  of  fauces,  61. 

Jaboulay  and  Braun,   gastrojejunostomy,  319. 
Jaw-bone,   lower,  59   (see   "Lower  jaw"). 

upper,   58   (see  "Upper  jaw-bone"). 
Jejunostomy,   328. 
Jejunum,  285. 
Jonnesco  operation,  170. 

Keen  bone  forceps,  392. 

Kidney,    abscess   of,    operation   for,  473. 

absence  of  one,  466. 

capsule  of,  466. 

decortication  of,  475. 

extirpation  of,   474. 

fixation  of   (see  "Nephropexy"). 

floating,   466. 

incision  into,   473. 

movable,  466. 

stone  in,   operation   for,   474. 

surgical  anatomy  of,  466. 
Knee-joint,  amputation  of  leg  at,  Carden,  586. 
Gritti-Stokes,  588. 
Stephen  Smith,  584. 

bursaB  adjacent  to,  583. 

resection  of,  Textor  incision,  606. 
Volkmann  incision,  611. 

surgical  anatomy,  581. 
Knot,  slip,   13. 

square,  13. 

surgeon's,  13. 
Kocher,  amputation  of  tongue,  172. 

pylorectomy,  27L 


624 


INDEX. 


Kraske,   amputation  of  rectum,   420. 
Kraske,  resection  of  rectum,   412. 

sacral  route  to  reach  rectum,  412. 
Kronlein's  modification  of  Lucke's  operation, 
83. 

Laminectomy,   391. 

Langenbeck,    extirpation   of   tongue,    176. 
formation  of  lower  lip,   119. 
incision  for  resection  of  upper  jaw,  71. 
Laplace  forceps,  305. 
anastomosis,    end-to-end,   with,   305. 

lateral,  with,  312. 
gastrojejunostomy  with,   324. 
Large  intestine   (see  "Intestine"). 

anastomosis  (see  "Intestinal  anastomosis   ). 
Laryngeal  region,   138. 
Laryngectomy,  153.  ( 

Laryngotomy,  transverse,  151  (see  also     Tny- 

rotomy"). 
Larynx,  138. 
extirpation  of,  153. 
half  of,  extirpation  of,  157. 
Lateral    anastomosis    (see    "Intestinal    anas- 
tomosis"), 
implantation  after  resection  of  cfficum,   341. 
Lateral  lithotomy,  496. 
nasal  clefts,  101. 

process,  89. 
pectoral  region,  190. 
sinus,  23. 
sternal  line,  184. 
Le  Fort,   exarticulation  of  foot,  577. 
Leg,  561. 
amputation  of,   578. 

with  lateral  hooded  flaps,   578. 
exarticulation   at   knee-joint,    Carden,    586. 
Gritti-Stokes,   588. 
Stephen   Smith,   584. 
varicose  veins  of,   ligation,   565. 
Lembert  suture,  17. 
Ligament,    Colles's    (triangular),   423. 
gastro-colic,   240,   268. 
gastro-hepatic,   239-268. 
gastro-splenic,  388. 
Gimbernat's,   424-438. 
hepatico-duodenale,  284,  357. 
ilio-pectineal,   433-438. 
Poupart's,  225,   423,  438. 
pubic,  of  Cooper,   431,  433,  438. 
sacro-sciatic,    greater    and    lesser,    552. 
of  Treitz,   285. 
triangular   (Colles's),   423. 
triangular   (perineum),   490,   499. 
Ligamentum    arcuatum    internum,    234. 
externum,   233. 
dentatum,  236. 
nuchae,  125. 
Ligation    of    arteries    (see    "Artery"). 

preliminary,   to  control  hemorrhage,  9. 
of  varicose  veins  of  leg,  565. 
Ligature,  control  of  hemorrhage  by,  12. 
Line,   axillary,  184. 
lateral  sternal,  184. 
mammary,  184. 
midsternal,  184. 
parasternal,   184. 
scapular,  185. 
Linea  alba,  225. 

semilunaris,   223,   225,   Fig.   176. 
Lingual   triangle,    132. 
Lip,  lower,   clefts  of,  103. 
excision  of,  116. 
restoration  of,   117. 
Bruns  method,  118. 
Dieffenbach-Jaesche,  117. 
Estlaender,   120. 
Langenbeck,  119. 
upper,   median   clefts  and  notches  of,   100. 


Lip,  upper,  restoration  of,  12L 
Lips,    operations   upon,    116. 

surgical  anatomy  of,  60. 
Lisfranc  amputation  of  foot,  569. 

joint,  567.. 
Lithotomy,   lateral,   496. 

median,  495. 
Little  toe,   exarticulation  of,  568. 
Liver,  cirrhosis  of,  operation  for,  360. 

incision  into   (see  "Hepatotomy"). 

injuries  of,  360. 

operations   upon,   359. 

resection  of   part  of    (see   "Hepatectomy"). 

round  ligament  of,  228. 

surgical  anatomy  of,   354. 
Longitudinal  sinus,  23. 
Lower  anterior  pectoral  region,  190. 
Lower  jaw,  59. 

median  clefts  of,  103. 

resection  of  entire  body  of,  81. 
of  half  of,  76. 
of  half  of  body  of,  79. 
of  part  of  body  of,    in    continuity,    81. 
not  in   continuity,   82. 
Lucke's    operation,    Kronlein's    modification, 

83. 
Lumbar  puncture,   393. 
Lung,  206. 

decortication   of   (see   "neurectomy  '). 

limits  of,  206. 

root  of,  205. 

Macewen,  osteotomy,  615. 
Macrostoma,  92. 

Malgaigne  operation  for  harelip,  106. 
Mammary  line,  184. 
gland,  188. 
region,  188. 
Mandibular  arch,  87. 
Mastoid  antrum,  46. 
drilling  into,  52. 
operations  upon,  52. 
to  open  and  drain,  52. 
process,   45,  46. 
pneumatic,  46. 

region,  surgical  anatomy  of,  45. 
Maxillary  bone,   inferior   (see   "Lower  jaw   ). 
superior   (see  "Upper  jaw-bone"), 
process,   inferior,   88. 
superior,  88. 
Maydl,  colostomy,  336. 

jejunostomy,   328. 
McBurney  incision,  344. 

point,  330. 
McGraw's  intestinal   anastomosis,   312. 

rubber   suture    gastrojejunostomy,    32L 
McLean  anastomosis  forceps,  305. 
Meckelii,   cavum,   37. 
Meckel's  ganglion,   70. 
Median  lithotomy,   495. 
Mediastinum,  190. 
contents  of,  190. 
Mesentery,  286. 
"dead   space"   of,   287. 
wounds  of,  252. 
Metacarpophalangeal    joints,    519. 

exarticulation  of  finger  at,   521. 
Microcephalia,   craniectomy  for,   30. 
Middle  ear,  49. 
fossa  of  skull,  32. 

extradural  abscess  in,  56. 
meningeal   artery,    hemorrhage   from,   26. 
nasal  process,  89 
Midsternal  line,   184. 
Mirault  operation  for  harelip,  107. 
Mitral  valve,  195. 
Mohrenheim  fossa,  187. 
Morison,  space  of,  358. 
Mounsell,    end-to-end    anastomosis,    297. 


INDEX. 


625 


Mouth,  60. 

floor  of.   62. 

roof  of,  61. 
Mouth-gag,   Whitehead,   113,   Fig.  61. 
Murphy       button,       cholecysto-duodenostorny 
with,    372. 
gastrojejunostomy   with,    320. 
intestinal   anastomosis  with,   303,   311. 
Muscle,  buccinator,  60. 

bulbo-cavernosus,    489. 

compressor    urethra?    (see    "M.    transversus 
perinei"). 

cremaster,   424-457. 

erector  spinse,   232. 

external    oblique,    224. 
aponeurosis   of,   225,   423. 

external  pterygoid,   66. 

gluteus  maximus,  551. 

iliacus,   234. 

ilio-psoas,   432. 

internal  oblique,  225. 

internal   pterygoid,   70. 

latissimus   dorsi,   231. 

levator   anguli    scapulae,    232. 

levator  ani,  491-492. 

masseter,  65. 

occipito-frontalis,    20. 

pectoralis  major,   186. 

pectoralis   minor,   186. 

platysma,  126. 

psoas,   234. 

quadratus   lumborum,    233. 

rectus,  226. 

rhomboideus,   232. 

sphincter   ani    (internal   and    external),    400. 
dilatation  of,  401. 

splenius,  232. 

sterno-hyoid,  137. 

sterno-mastoid,    125. 

sterno-thyroid,    137. 

subclavius,  186. 

subcostales,   182. 

temporal,  21. 

transversalis  abdominis,   226. 

transversus   perinei,   49J. 
deep,  490. 

trapezius,  231. 

triangularis  sterni,  182. 
Muscles,   intercostal,   182. 

of  back,  231. 

of  chest  wall,  182. 

Nasal  clefts,  lateral,  101. 
process,   lateral,   89. 
middle,   89,   91. 
Neck,   back  of,  125. 
blood-vessels   of.   141. 
front  of,  134. 
operations  upon,  147. 
sides  of,  125. 
surgical  anatomy  of,  123. 
Nelaton  operation  for  harelip,   105. 
Nephrectomy,    474. 
Nephrolithotomy,  474. 
Nephropexy,   467. 

Edebohls,  470. 
Nephrotomy,   473. 
Nerve,    anterior   crural,   557. 
anterior  tibial,  562. 
auriculo-temporal,  65,   69. 
facial,  51,  58,   65. 
fifth  (trifacial),  35,  69. 
division    of    branches    at    base    of    skull. 
Kronlein-Lticke,   83. 
of  peripheral   branches,   85. 
inferior  maxilary  branch,   36,  69. 
ophthalmic  branch,   35. 
superior  maxillary  branch,  35,  69. 
glosso-pharyngeal,  64. 


Nerve,   gustatory   (lingual),   64. 

hypoglossal,    64,   132. 

lingual    (gustatory),   64. 
division  of,  85. 

median,  514. 

musculo-spiral,   514. 

posterior  tibial,   564. 

sacro-sciatic,    stretching,    552. 

spinal  accessory,  133,   143. 

sympathetic,    cervical,    169. 
surgical   anatomy   of,    169. 
resection  of,   170. 

suture  of,  16,  548. 

trifacial   (see   "fifth"). 

ulnar,  514. 

vagus    (see   "Nerves,    pneumogastric"). 
Nerves,  inferior  recurrent  laryngeal,  138,  197. 

of  neck,  superficial,  127. 

of  tongue,   64. 

phrenic,   133,   197. 

pneumogastric,   196. 
Neural  tube,  85. 
Nipple,  188. 
Nitrous  oxide,  2. 

Oblique  facial  clefts,  91,  101. 
Obturator  fascia,  491. 

foramen,   439. 
Occipital  triangle,  132. 
CEsophago-duodenostomy,    281. 
(Esophago-jejunostomy,    281. 
QHsophagostomy,   162. 
CEsophagotomy,    external,    161. 
CEsophagus,  138,  198. 

relations  of,   199. 

stricture    of,    operation    for    (see    "Gastrot- 
omy,"   251). 
O'Hara  forceps,  307. 

anastomosis,   end-to-end,  with,   307. 
lateral,  with,  312. 

gastro-jejunostomy  with,  324. 
Olfactory  groove,  89-91. 
Omentopexy,  360. 

Ophthalmic   division    (see   "Nerve,   fifth"). 
Oral  pit,   88. 

plate,  85. 
Orbito-nasal  cleft,  91,  101. 
Osteoclast,  6. 

Osteotomy    (Macewen),    615. 
"Outside    serous"    suture,    13. 

Palate,  61. 

cleft,  98. 
operation  for,  112. 

formation  of,   93. 
Pampiniform  plexus,   457. 
Pancreas,   cysts  of,  384. 

fat  necrosis,  382. 

injuries   to,   383. 

operations  upon,  381. 

surgical    anatomy   of,    379. 

tumors  of,  386. 
Pancreatic   duct,    285,    358,    3S0. 
Pancreatitis,    acute,    operation    for,    385. 
Parasternal   line,   184. 
Parotid  gland,  65. 
Patella,   suture  of,   616. 
Pectineal  fascia  (pubic  portion  of  fascia  lata), 

438. 
Pectoral  region,   lateral,   190. 
lower  anterior,   190. 
upper  anterior,  185. 
Pelvic  cavity    (from   within),   491. 

floor   (from  within),   492. 
Pelvis,    floor   of    (from   without    inward),    4S7. 
Penis,    amputation   of,    485. 

surgical  anatomy  of,   481. 
Pericardium,    191. 
Pericardii,  paracentesis,  214. 


626 


INDEX. 


Pericardiorrhaphy,   215. 
Pericardiotomy,   214. 
Pericranium,    21. 
Perineal   fascia,    deep,   490. 
superficial,  4S7. 

section  with  guide,  493. 
without  guide,  494. 
Perineum,  surgical  anatomy  of,  489. 
Peritoneum,    parietal,    227. 
Phalango-phalangeal  joints,  51S. 

exarticulation  of  fingers  at,   519. 
Pharyngeal  membrane,   90. 
Phimosis,  operations  for,   482. 
Pia  mater,  24,  236. 
Piles    (see    "Hemorrhoids"). 
Pirogoff  exarticulation  of  foot,  575. 
Plate,   frontal,   88,   89,   92. 
Pleura.  201. 

anterior  edge  of,  202. 

dome  of,   204. 

excision  of,   219. 

lower  edge  of,  203. 
Pleurectomy,  Fowler,  219. 
Plica  epigastrica,  435. 

vesico-umbilicalis   lateralis,   435. 

vesico-umbilicalis  media,   435. 
Plication    of    gastro-hepatic    ligaments,    241. 
Popliteal  space,  560. 
Poppert,    cholecystostomy,   369. 
Posterior  triangle  of  neck,  127. 
Poupart's  ligament,  225,  423,  438. 

space  beneath,   432-438. 
Pra?visceral  space,  124. 
Prepuce,   operations  upon,   482. 
Process,  frontal,  88,  89,  92. 

inferior  maxillary,   88. 

infundibular,  425,  426,  428,  435. 

lateral  nasal,  89,  92. 

mastoid    (see    "Mastoid   region"). 

middle  nasal,   89,  92. 

superior  maxillary,  88,  93. 
Prostate  gland,   491-496. 
Prostatectomy,  499. 

perineal,  500. 

suprapubic,  499. 

Young,  503. 
Prostatotomy,    Bottini,   504. 
Pterygo-maxillary  region,   64. 
Pubic  ligament  of  Cooper,  431,  433,  438. 

portion  of  fascia  lata,  431. 
Pulmonary  valve   (orifice),  194. 
Purse-string  suture,   Murphy  button,   303,  311. 
Pylorectomy,  267. 

Billroth,   267. 

Kocher,  271. 

use  of  Murphy  button,   274. 
Pyloroplasty,    Heinecke   and   Mikulicz,    252. 

Finney,  253. 
Pylorus,   resection  of   (see   "Pylorectomy"). 

Rectal  wall,  excision  of  part  of,   405. 

polypi,  407. 
Rectum,   amputation,   Kraske,   420. 
Volkmann,  407. 

blood-supply  of,   400. 

operations   upon,   401. 

resection   of,    Dieffenbach,    410. 
Kraske,   412. 

sacral   route   to   expose,   Kraske,   412. 

surgical  anatomy  of,  397. 
Regio  abdominis  lateralis  dextra  and  sinistra, 
229. 

epigastrica,  229. 

hypochondriaca,    dextra   and   sinistra,    229. 

inguinalis,  229. 

mesogastrica,  229. 

pubica,  229. 

umbilicalis,   229. 
Region,    femoral,    from   within    abdomen,    437. 


Eegion,  clavicular,   186. 
femoral,  431,  437. 

from  within  abdomen,   437. 
gluteal,  551. 
infraclavicular,   187. 
infrahyoid,  335. 
inguinal,  422. 

from  within   abdomen,   434. 
ischio-rectal,   488. 
laryngeal,  138. 
lateral  pectoral,  190. 
lower  anterior  pectoral,   190. 
mammary,   188. 
mastoid,   45. 
pterygo-maxillary,    64. 
sternal,  185. 
sterno-mastoid,  128. 
suprahyoid,  135. 
suprasternal,  140. 
upper  anterior  pectoral,  185. 
Regnoli-Billroth  amputation  of  tongue,  174. 
Reid's  base-line,  47. 
Remak,  racheuhaut  of,  90. 
Resection  of  ankle-joint,   Koenig,  601. 
Langenbeck-Hueter,   597. 
Lauenstein,   603. 
Mikulicz-Wladimirow,   604. 
with  extirpation  of  astragalus,   600. 
of  caecum,   338. 
of  elbow-joint,   543. 
of  hip-joint,    Langenbeck    incision,    611. 

Anthony   White   incision,   613,    Fig.    263. 
of  intestine   (see   "Enterectomy"). 
of  knee-joint,    Textor  incision,    606. 

Volkmann  incision,  611. 
of  lower  jaw,  half,  76. 
entire  body  of,  81. 
half  of  body  of,  79. 
part  of  body   in   continuity,   81. 
not  in  continuity,   82. 
of  pylorus   (see   "Pylorectomy"). 
of  rectum    (see    "Rectum"), 
of  rib,  218. 

of  skull,   temporary,  27. 
of  shoulder-joint,  545. 
of  temporo-maxillary   joint,   82. 
of  upper  jaw,  70. 

of  both  upper  jaws,  75. 
of  wrist-joint,  541. 
Retrovisceral  space,  124. 
Retzius,  space  of,  477. 
Rib,  first,  180. 

resection  of  (thoracotomy),  218. 
Ribs,  180. 

Ring,  crural,   434-439. 
inguinal,  external,  423. 
internal,  425,  426. 
Robson,   gastrostomy,   258. 
Rose  position,  10,  70. 

Rose-Andrews,     extirpation     Gasserian     gan- 
glion, 42. 
Roser,   dorsal  section,  483. 
Roux,   gastro-jejunostomy,   326. 

Sacral  route,   rectum,  412. 

Sacrum,   397. 

Saline  infusion,  intravenous,  549. 

Santorini,   duct  of,  381. 

Saphenous  opening,  432,  554. 

Scalp,  20. 

Scapular  line,  185. 

Scarpa's  triangle,  555. 

Schlatter,   gastrectomy,   280. 

Schleich  infiltration  method,  3. 

Sciatic  nerve,   stretching,   552. 

Scrotum,  428,  457. 

Sedillot,  extirpation  of  tongue,  175. 

Seminal  vesicles   (see  "Vesiculas  seminales"). 

Serous  surfaces,  suture  of,  17. 


INDEX. 


627 


Shoulder-joint,  exarticulation  at,  deltoid  flap, 
538. 
Spence  method,  534. 
with  Esmarch   constrictor,  536. 
resection   of,    545. 
surgical   anatomy   of,   532. 
Side  of  neck,  125. 

Side-to-side  anastomosis   (see   "Intestinal  an- 
astomosis"). 
Sigmoid  flexure,   anatomy  of,  332. 
resection  of,    342. 
sinus,  33,  45   (see  "Lateral  sinus"), 
thrombosis  of,  54. 
Sinus,   cavernous,   23,   34. 
frontal,  22. 

trephining  of,   31. 
lateral,  23. 
longitudinal,  23. 
phrenico-costalis,   207. 
sigmoid   (lateral),    33,   45. 
thrombosis  of,  54. 
Skin,  suture  of,  14. 

intracuticular,  15. 
Skull,  21. 
middle  fossa,  32. 
temporary  resection  of,  27. 
trephining   for  depressed  fracture,   24. 
Slip  knot,  13. 

Small   intestine,   284    (see    "Intestine"), 
anastomosis  (see  "Intestinal  anastomosis"), 
blood-supply  of,  287. 
operations  upon,  288. 
surgical  anatomy  of,  284. 
Smith   (Stephen),  amputation  of  leg  at  knee- 
joint,  584. 
Soft  palate,  62. 
Soft  parts,  division  of,  5. 
Space,  femoral,  433,  438. 
prsevisceral,  124. 
retrovisceral,  124. 
subarachnoid,   brain,   24. 

spinal  cord,  236. 
subdural,   cranium,  24. 

vertebral,   236. 
vascular,   124. 
Spence,    exarticulation    of    arm    at    shoulder- 
joint,   534. 
Spermatic  cord,  424,  456. 

fascia,  422,  457. 
Spheno-maxillary  fossa,  68. 
Sphincter  ani   muscles,  400. 

dilatation  of,   401. 
Spina  supra  meatum,   46. 
Spinal  column,  234. 
cord,  235. 
dura  mater  of,  236. 
pia  mater  of,  236. 
Spleen,   excision  of,  390. 
incision  into,   388. 
operations  upon,  388. 
surgical  anatomy  of,   387. 
Splenectomy,   390. 
Splenopexy,  389. 
Splenorrhaphy,    389. 
Splenotomy,   388. 
Square  knot,  13. 
Ssabanajew-Franck  gastrostomy,   257. 

Robson  modification,  258. 
Staphylorrhaphy,    113. 
Stenson's  duct,  61-65. 
Sternal  region,  185. 
Sterno-mastoid  region,   128. 
Sternum,   181. 
Stomach,  237. 
closure  of  wounds   of    (gastrorrhaphy),   262. 
excision  of   (see   "Gastrectomy"), 
foreign  bodies  in,   operation  for  (see   "Gas- 

trotomy"). 
incision  into    (see   "Gastrotomy"). 


Strmach,  operations  upon,   241. 

surgical  anatomy  of,   237. 
Stricture,    urethral,   perineal   section   for,   493, 
494. 
suprapubic  cystotomy  for  impassable,   495. 
Styptics,  11. 

Subarachnoid  space,   brain,  24. 
spinal  cord,  236. 

injection    of    cocain,    4    (see    also    "Lumtar 
puncture"). 
Subclavian  triangle,   133. 
Subdural   space,    cranium,   24. 

vertebral,  236. 
Sublingual   glands,    63. 
Submaxillary  gland,  131. 

triangle,  131. 
Submental   triangle,   135. 
Superficial  fascia  of  groin,  421. 
Superior  maxilla   (see   "Upper  jaw-bone"). 
Superior  maxillary  branch  of  fifth  nerve,   35, 
69. 
process,   88,  93. 
Suprahyoid    region,    135. 
Suprapubic   cystotomy,   478. 
Suprasternal  region,  140. 
Surgeon's  knot,   13. 
Suture,  Cushing,  18. 

Halsted,   18. 

Lembert,   17. 

material,  14. 

of  bladder,  19. 

of  bone,  16. 

of  bowel,  17. 

of  cartilage,  16. 

of  muscle,  15. 

of  nerve,  16,  548. 

of  patella,  616. 

of  serous  surfaces,  17. 

of  skin,  14. 
intracuticular,   15. 

of  tendon,  16,  548. 

of  tissues,   14. 
Syme,   exarticulation  of  foot,  574. 

Talma's  operation,   360. 

Tampon   cannula,   Trendelenburg,   147. 

Tamponade  to  control   hemorrhage,   11. 

Tarsus,   566. 

Tear-duct,   91. 

Teeth,   development  of,  94. 

Temporal   fascia,   20. 

Temporary   resection   of  skull,    27. 

Temporo-maxillary   joint,    resection   of,    82. 

Temporo-sphenoidal   abscess,   57. 

Tendon,  suture  of,  16,  548. 

Tenotomy,  564. 

of  flexor   longus   digitorum,   564. 

of  tendo  Achillis,  564. 

of  tibialis   posticus,   564. 
Testes,  descent  of,  428. 
Testis,   457. 

extirpation  of,  464. 

operation   for  undescended,   452. 
Thigh,   551. 

amputation  of,   5S9. 

exarticulation  of,   at  hip-joint   (Wyeth),  594. 
with     preliminary     ligation     of     common 
femoral,   597. 
Thoracectomy    (Estlaender),    219. 
Thoracentesis,   217. 
Thoracic  aorta,  200. 

duct,  201. 

wall,  muscles  of,   182. 
Thoracotomy,  218. 
Thorax,    aspiration    (see    "Thoracentesis"). 

fasciae  of,   1S2. 

operations   upon,   207. 

regions  of,  184. 

resection  of  wall   of,   219. 


628 


INDEX. 


Thorax,   skeleton   of,   179. 

tapping    (see    "Thoracentesis"). 
Thrombosis  of  sigmoid  sinus,   54. 
Thymus   body,   195. 
Thyro-hyoid   membrane,   137. 
Thyroid  cartilage,  135. 

gland,  139. 
Thyrotomy,   151. 
Toe,  amputation  of,  568. 
Toe-nail,   operations  for  ingrowing,   569. 
Tongue,  63,  94. 

operations  upon,   172. 

amputation,  with  division  of  lower  jaw,  175. 
Kocher,   with  preliminary  ligation  of  lin- 
gual,  172. 
Regnoli-Billroth,  174. 
Whitehead,  177. 

clefts  of,  103. 

development  of,  94. 

extirpation   of,    with   division   of  lower  jaw, 
175. 
Billroth,  177. 
Langenbeck,  176. 
of  half,  Whitehead,  177. 
Sedillot,  175. 

nerves  of,  64. 
Torsion,  12. 
Trachea,  138,  197,  205. 

tampon  of,  147. 
Tracheotomy,  147. 

high,  148. 

low,  149. 

median,  150. 
Transversalis  fascia,   227,   425,   428. 
Transverse  colon,   anatomy  of,   332. 

facial  cleft,  92,  103. 
Treitz,    ligament   of,   285. 
Trendelenburg  position,   9. 

tampon  cannula,  147. 
Trephine,   removal  of  button  of  bone,   29. 
Trephining,  24. 

for  depressed   fracture  of  skull,   24. 

for  hemorrhage  from  -middle  meningeal,  26. 

for  intracranial   hemorrhage,   26. 

of  frontal    sinus,   31. 
Triangle  of  neck,    anterior,   127. 

inferior   carotid,   128. 

lingual,  132,  168. 

occipital,  132. 

of  Pettit,  225. 

posterior,  127. 

Scarpa's,  555. 

subclavian,  133. 

submaxillary,   131-168. 

submental,  135. 

superior   carotid,   130. 
Triangular  ligament   (groin),   423. 

(perineum),   490,   499. 
Tricuspid  valve,   195. 
Tunica  vaginalis  testis,   429,   457. 
Tympanum,  49. 
Typhoid   perforation,    operation   for,    291. 

Upper  anterior  pectoral  region,   185. 
Upper  jaw-bone,   58. 

resection  of,  70. 
Upper   jaw-bones,    resection    of    both,    75. 
Upper  lid,  median  clefts  and  notches  of,  100. 

restoration  of,   121. 
Uracus,   228. 
Uranoplasty,   114. 
Urethra,  bulb  of,  481,  489. 

membranous    portion   of,    490. 

perineal   section   for  stricture  of,   493. 

prostatic  portion  of,   497. 


Urethra,  suprapubic  cystotomy  for  impassable 

stricture   of,    495. 
Urethrotomy,   external,   with  guide,  493. 
without  guide,  494. 

Vaginal  process  of  peritoneum,  429,  435. 
Valve,  aortic,  194. 

mitral,  195. 

pulmonary,   194. 

tricuspid,  195. 
Varicocele,   open   operation,   458. 
Varicose  veins,   ligation  of,  565. 
Vas  deferens,   456,   458,   498. 
Vascular  space,   deep   cervical   fascia,   124. 
Vater,   ampulla  of,   357,   380. 
Vein,    anterior   jugular,    126. 

axillary    (see   "Artery,    axillary"). 

azygos,   200. 

basilic,  511. 

cephalic,   187,  509. 

external  jugular,  126. 

facial,   131. 

femoral    (see    "Artery,    femoral"). 

hemiazygos,   201. 

inferior  thyroid,  140. 

internal   jugular,    130,    144. 
ligation   and   excision   of,   55. 

internal  saphenous,   554. 

pulmonary,   206. 

subclavian.  146. 

temporal,   66. 

temporo-facial,   66,   144. 
Velpeau   incision   for  resection   of  upper  jaw, 

71,    Fig.    22. 
Vermiform   appendix    (see    "Appendix   vermi- 

formis"). 
Vertebras,   dorsal,  180. 

Vertebral   column    (see    "Spinal    column"). 
Vesicle   of    forebrain.    86. 
Vesiculas   seminales,   491. 
Vicious    circle    (gastrojejunostomy),    319. 
Visceral    arches,    87. 

clefts,  87. 
Vocal  cords,  138. 
Vogt's  lines,  29. 
Volkmann,   amputation  of  rectum,  407. 

operation    for   hydrocele,    46i. 
Von   Bergmann   operation    for   hydrocele,    462. 
Von   Grafe   operation   for   harelip,    105. 
Von   Hacker,    gastrojejunostomy,    317. 

gastrostomy,   255. 

incision,  255. 

Wagner,    temporary  resection  of  skull,   27. 
Weber's  incision  for  resection  of  upper  jaw, 

70. 
Wellenschnitt,   Dieffenbach's,   108,   110,   121. 
Wharton's  duct.   63,   131. 
Whitehead   amputation   of   tongue,   177. 

mouth-gag,   113,   Pig.   61. 
Wilde's  incision,   52. 
Winslow,   foramen  of,   359. 

examination  of  bile-ducts  through,   363,  3C9. 
Wirsung,   duct  of    (see   "Pancreatic   duct"). 
Witzel,   gastrostomy,   259. 
Woelfler,   gastrojejunostomy,   313. 
Wrist-joint,  exarticulation  of  hand,  Dubrueil, 
525. 

resection  of,  541. 

surgical   anatomy  of,   524. 
Wyeth,    exarticulation    of    thigh   at   hip-joint, 

594. 
Wyeth's  pins,   594. 

Zygomastic  fossa,   67. 


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